JAMAICA VOTES - Country can afford to abolish health fees

Published in the Jamaica Gleaner: Thursday | August 30, 2007

Prime Minister Portia Simpson Miller recently suggested that the Opposition Leader follow the advice of popular deejay Mr. Vegas and 'tek weh' himself.

She was referring to what has been the Jamaica Labour Party's (JLP) habit of making big promises more concerned with impressing voters than budgeters. After education, health has become the second issue area which, in this election season, has had a great philosophical question attached to it: 'To fee, or not to fee?' The People's National Party (PNP) sings a mantra of 'Nothing is free. Everything must cost us something', while the Jamaica Labour party (JLP) continues to say elliptically, 'We can find the money'.

Like the topic of education, thebig hoopla over fees has diverted the public's attention from a simple fact: the manifestos do not differ greatly. The JLP's proposal to abolish health fee and the ruling party's present policy of not turning away anyone who cannot afford said fees, amount to almost the same thing. Other areas of convergence in the two manifestos include the promotion of HIV/STD awareness and healthy lifestyle programmes, the establishment of community health programmes, the expansion of mobile clinic systems, the upgrading of parish hospitals to include a wide range of specialist services, the expansion of emergency medical services and also the immunisation programme.

Can the JLP find the money ($1.6 billion) to provide free health care to all? The Caribbean Policy Research Institute (CaPRI) actually believes the JLP have its feet more firmly on the ground than with other ambitious promises they have made. Our research suggests the abolishment of health fees is something the country can afford. A few myths need to be debunked to make the point. Firstly, no matter how tightly we cross our fingers, free health care will not translate into a free bed, and personal care for every jack man in the exclusive Tony Thwaites Wing of the University Hospital. Private health care will still cost money and, we believe, will continue to be the preferred option for those who can afford it and who would be 'impatient' to be put on any government wait list.

This indeed is the present situation; those burdened with the very minimal health fees charged ($300 for registration at health centres, $1,000 for minor operations) are generally the poorest of the society. User fees, in fact, amount to only 0.39 per cent of the national health budget and so it would be almost a preposterous case to make out that these fees, in any significant way, sustain the delivery of health in the country. Some health-care professionals we interviewed have further hypothesised that the abolishment of fees might lead to a healthier population if only because it encourages more people to come in for diagnosis for various illnesses at an earlier stage.

A complicated problem

Free health care, by whatever name it is called, will prove a far greater burden to the health sector's human resource rather than its financial resources. This is a real concern since both parties propose, however vaguely, to build more hospitals. Who exactly will staff them? The country continues to face a shortage of nurses and the Kingston Public Hospital, which right now has three or four operating theatres, only operates one because it simply does not have enough specialist doctors (surgeons, paediatricians, obstetricians, for example) to make use of the facilities.

Increasing the number of facilities, therefore, isn't a well thought out proposal from either party if there is no one to work in them. The parties, of course, want to train and recruit more professionals and it is at this juncture that the former question becomes more appropriate: Where are we going to find the money? Right now, 70 per cent of the health budget is used to pay salaries. This means that only a relatively small percentage is used on research, maintaining clinics and buying supplies, importing necessary machines or equipment, etc. Simple mathematics, therefore, means that to put more persons onto the health payroll (something CaPRI does acknowledge is necessary) will mean an even smaller piece of the pie going to other aspects of the health service. Take for instance the need for more drugs. Already there has been an increase in the demand for pharmaceutical supplies. Between 2002 and 2003, the total number of clients using public sector pharmacies increased from 688,801 to 733,882 and the items.

Comparative analysis of the PNP and JLP manifestos - Health

Some points of agreement *** Some points of disagreement

a. Intensify the promotion of healthy lifestyle programmes.

b. Promote awareness in areas such as HIV and other STDs.

c. Continue to promote the establishment of health community programmes.

d. Provide strategically located health centres to facilitate assessments and initial treatment in order to reduce hospital overloads.

e. Increase and upgrade the number of community health aides.

f. Expand mobile clinic systems.

g. Expand emergency medical services.

h. Upgrade parish hospitals to offer a wide range of specialist services.

I. Attract and train medical staff

j. Develop new medical technologies

k. expand immunization programme

l. Encourage responsible parenthood through Family Planning programme

JLP

Significantly increase the inflows into the National Health Fund.

Improve referral system to explain the use of primary and secondary health facilities.

Work along with NGOs to expand facilities for residential care of HIV/AIDS patients.

Abolish user charges at all public health facilities including public hospital.

Expand specialist services at Bustamante Children's Hospital.

Upgrade Bellevue to a neuro-psychiatric institution.

Establish well-equipped diagnostic and treatment centres at specific hospitals to provide specific services such as ultrasound etc.

Remove all import duties on the importation of medical equipment and technology.

Provide tax credits for health insurance premiums paid by employees and employers.

PNP

Provide the opportunity of offshore training for some medical staff

Provide treatment for HIV infected persons

Continue to support the building, upgrading, equipping of health facilities and related training facilities

Opening of a new hospital in Portmore

Construction of specialist children's hospital and facilities for the terminally ill in western Jamaica

Continue to ensure the provision diagnostic equipment and supplies at all levels

Provide short term mental health treatment facilities at specific hospitals

Ongoing provision of emergency air transport

Trainand employ emergency care staff to national and international standards for ambulance services

Provide more doctors at primary care clinics.

increased from 1,895,607 to 1,989,267.

Our own estimates reveal that by the end of the first term, if they both plan to train the required number of nurses, they will have to spend over $3.6 billion. This is money that needs to be spent. Studies by the National Academy of Sciences show that patients are endangered when nurses are required to work more than 12 hours a day as fatigue reduce productivity. Studies further show that increased infections, bleeding and cardiac and respiratory failure are associated with inadequate numbers of nurses and that nurses defend against medical errors, intercepting 86 per cent of medication errors before they reached patients.

Ongoing battles

Public Health management also needs urgent attention and money. Our recent and ongoing battles to control both malaria and leptospirosis outbreaks highlight this issue. According to the Economic and Social Statistics of Jamaica for 2006, the number of leptospirosis cases in humans doubled in 2005, compared with the corresponding period. The outbreak was responsible for seven deaths in Clarendon, Manchester and St. Elizabeth that year. While the ministry and other public authorities sought to deal with the rat infestation problem, they faced challenges in eliminating the breeding ground for rodents as the laws regulating proper disposal of organic waste were not being rigorously enforced.

Throwing yet another spanner into the works: the plans to build more clinics or hospitals is a little short-sighted, especially when we are not told the size of these hospitals or what they might specialise in. Jamaica needs more than just a greater number of hospitals - we need hospitals that cater exclusively to cardio patients, or one that can specialise in male-health-related issues. Both parties express plans to expand the emergency medical services (EMS) but we are unsure ifhave they considered the finding that an all-island EMS coverage can only be provided by 45 EMS sites with at least two ambulances and two crews each. We currently use three crews and have very few EMS sites.

This all amounts to a dynamic and complicated set of problems looming over our health sector. Both manifestos spend a great many pages talking about health, but neither seem to have a solid grasp of the extent of what might need to be done or realistic, strategic plans on how to accomplish it. The truth is, many urgent things need to be done, and we do not have the money to do them all. What then is the real priority of either prospective government, and what tangible improvements can the public reasonably expect? The fact that so much time and energy has been wasted on the debate over fees is evidence of both parties being divorced from the more substantial matters concerning health. The answer to the question, 'To Fee or Not to Fee', will hardly be the beginning to any solution that would see significant transformation to health delivery in Jamaica.

CaPRI welcomes all comments, responses and suggestions on this and other articles in the Manifesto Analysis series. Please contact us attakingresponsibility@gmail.com.