Introduction and Purpose of Research

This research will be an investigation into the extent to which free health care or no user fee

policy affects the quality of health care offered at the Kingston Public Hospital? It will seek

to answer the following questions:

Please insert your aims here

The health care system is one of the most important organizations within a country as it

looks after the health, wellbeing and wellness of its citizens. The care of citizens is one of the

prime responsibilities of this sector. Health care centres are placed in different areas to facilitate

giving proper health care to residents. Recently, the health sector has been plagued with

numerous issues, such as: improper treatment of patients, deplorable infrastructure, poor

sanitization of facilities and avoidable fatal casualties to patients and other individuals who use

these facilities due to inadequacies, etc. These issues can all be linked back to the management of

these facilities, as well as, how the economy is being used, in terms of this sector.

Approximately, 7 years ago, a no user fee policy was implemented by the then

Government of Jamaica (Bruce Golding-led Administration), where all fees were removed from

most, if not, all public health facilities. This policy was quite useful as it allowed for citizens

from all social class to access affordable health care; not to mention we were in global

recession. However, it has been argued that the efficiency and quality of care has deteriorated

tremendously. To each choice, there are advantages and disadvantages; and this was no

exception as this policy raised multiple issues or concerns like those that were previously

highlighted.

1|Page
 The purpose of this study is to show the true effects that the policy has on the quality of

health care offered in local clinics and also to educate and sensitize persons on the role the

economy plays on the health sector and the value it places on it. Personally, I have had a first-

hand view of both the good and bad quality of health care offered; hence, why in this study I will

seek not only highlight the negative but also the positive aspects. Most of all, this study should

educate individuals on issues facing the economy and give possible solutions. It is my belief that

there needs to be a subsidized fee assigned to health care, where it is standard and affordable to all

individuals. Consequently, this would provide a balance to the economy and aid in sustaining

these facilities along with other source of financing.

Key Terms

Here are a few of the terms that may be used throughout the study:

Quality of Health Care - describes whether the delivery of clinical care, including

inpatient, outpatient, and diagnostic services, is appropriate, safe, and timely.

Efficiency- Making the best use of available resources; i.e. getting good value for

resources.

Fee- A charge for a service rendered.

Charge- The amount asked for a service by a health care provider.

Cost- amount the provider incurs in furnishing the service.

Financing- In health care finance, these are the methods of gaining, and the sources of,

revenue in health services. Modes of financing may vary.

Health Care Costs- The actual costs of providing services related to the delivery of

health care, including the costs of procedures, therapies, and medications.

2|Page
Health (Care) Policy- Decisions, usually developed by government policymakers, for

determining present and future objectives pertaining to the health care system.

Health Care Reform- Innovation and improvement of the health care system by

reappraisal, amendment of services, and removal of faults and abuses in providing and

distributing health services to patients.

Health Care Sector- Economic sector concerned with the provision, distribution, and

consumption of health care services and related products.

Quality- Quality healthcare is how well a healthcare provider keeps its members

healthy or treats them when they are sick.

Free or no-user fee- without cost or payment.

Care- the provision of what is necessary for the health, welfare, maintenance, and

protection of someone or something.

Health- the state of being free from illness or injury and a person's mental or physical

condition.

Quality- the standard of something as measured against other things of a similar kind;

the degree of excellence of something.

Economy- careful management of available resources.

3|Page
 Literature Review

In previous years, several investigations have been carried out on the effects of the free

health care policy, not only in Jamaica but throughout the Caribbean region and all over the

world. Those investigations have led to mixed response but at some point intersected at a

particular view, even though there may be different resolutions. Some have called for this policy to

be abolished while some are just requesting that it only needs further development and

management of finances allocated to this sector. However, as we go further into this research and

delve more and more into this policy, this paper will seek to inform the reader of the various

views person may have on this, including those highlighted earlier. This has been an issue over

many years, so the limiting factor is that the various source of publications required may not be

easily accessible even though this is usually an area of concern.

There has been a boost of support since the 1980s, for the introduction of user-fees in

public health facilities in developing countries, including Jamaica. This has resulted in

institutions, such as the IMF and the World Bank, calling for pro-market reforms. This user fee

has caused many injustices among citizens, which have reportedly caused them to be turned

away from public health facilities simply because they could not afford it. This gave rise to the

implementation of the No-User fee policy in 2008, which is the epicentre of this study. The

Bruce Golding led administration sought to find a way to bring some form of social justice to

this issue which was a form of classism; due to the mere fact that those of the lower classes could

not afford it.

In May 2013, a study done by CaPRI (Caribbean Policy Research Institute) on the matter

of the No User Fee Policy in Public Hospitals in Jamaica was published. The study basically

4|Page
did an overview of the whole situation since its implementation, as it sought to identify which

policy would be better for the people fee or free? On April 1, 2008 the Government of

Jamaica reversed its policy by removing user fees for services at public hospitals, heralding a

commitment to universal access to healthcare. The national debate as to whether the public purse

can sustain a quality healthcare service for the benefit of the most vulnerable social groups has

only been met with anecdotal evidence. This study compiled the results of a nationwide survey

of public hospitals which investigated the effect of the no-user fee policy on health services in

Jamaica. It revealed that the abolition of user fees has resulted in loss of financial resources for

the sector, negatively affecting pharmaceutical and medical supply stocks, staffing, waiting

times, space, service delivery and processing time. It further suggested that if the policy is to be

maintained, it must be accompanied by reforms that will substitute for the loss of financial

resources.

Although this health reform, has its positive implications it have also left some bad taste

in the mouth of citizens even years after its implementation. This has led to the Dr Winston

Dawes and the custos of Clarendon William 'Billy' Shagoury crying foul that this policy has to

go through an article published January 4, 2016 in the Gleaner dubbed No User Fee Must Go!

Clarendon Leaders Want Drastic Changes For 2016 in relation to the negative impacts the

people of May Pen have been enduring. Previously, in an article dated February 2015 published

by Dr Chris Tufton entitled Time to Review the No-User-Fee Policy? similar sentiments were

expressed in relation to health facilities in May Pen. This article came after volumes of concern

and protests from both patients and doctors at the May Pen Hospital that past week as yet another

example of a Jamaican health sector in crisis. It spoke of the claims by patients of very long

5|Page
waiting hours to see a doctor and a shortage of beds and medical supplies and more of the effects

this policy has on the Health Sector.

Despite most of the sources speaking of its effect on Jamaican Nationals; lets not forget

those in the Diaspora. It was pretty intriguing when this journal entry popped up illustrating the

concerns that they (citizens in the Diaspora) have on this policy; as well as, they expressed the

possible repercussions that they may face as a result of it, if they return lets say after retirement.

Vol. 61, No. 2 entered into the West Indian Medical Journal in March 2012 was entitled

Healthcare in Jamaica mainly gave concerns that the returnee residents have with this no user

fee policy. It was a bearer of good and bad news as they thought it was good that health care in

Jamaica was free to all citizens and legal residents at government hospitals and clinics but it took

an about turn as it began to lament on the services and conditions available due to this freeness.

This is evident where the writer expresses that, its not all good, one of the drawbacks to free

health care is the very long lines and poor service, with a no appointment booking system

accepted by the physicians. It then gave an illustration from a secondary source (local

newspaper) where stories have been told of person going to the hospital very early and leaving

very late with little or no medical assistance. Another illustration, which seemed to be a personal

experience, was that the writer now finds it rarely uncommon for scores of persons to be seen

gathered at hospital pharmacies hours prior to its opening and then when open just to hear that

they are lacking in supply in the medication you want. Many would love to access the private

doctors and clinic which are widely available but they dont have funds or insurance to cover the

cost.

Similarly to the cries in Jamaica, There seems to be no end to the stories of the national

public health system inn Trinidad failing to deliver quality healthcare to patients who go there

6|Page
for services. This was revealed in an editorial published by The Guardian Newspaper in

September 2011. It highlighted the most recent incident which involved the death of a 33-year-

old woman at the San Fernando General Hospital. She reportedly died after undergoing a C-

section at the southern hospital. Even though it was too early to say definitively whether or not the

hospitals care system was deficient, which may have resulted in the death of the woman.

Nevertheless many had the notion due previous performances by the facility which may have not

been up to the international accepted standard. They even conspired that the incident could have

been avoided if the system had performed up to standard. The editor continued to voice the

concerns of the citizens and patients arising from this incident.

In contrast to Jamaica, Barbados has long been known as one of the healthiest places in

the world and its healthcare reflects this. According to (Healthcare in the Caribbean, 2016) they

have a very high standard of healthcare and it is accessible to all citizens. Their main hospital,

the Queen Elizabeth Hospital, has the capacity to accommodate over 600 patients and also offers

a variety of specialized treatments. Similarly, however, the citizens of Barbados are entitled to

free health care same as Jamaicans but as a result of the agreement they have with UK.

Additionally, they have subsidized prescription fees for children and the elderly; hence

everybody else that fall outside of those age groups would have to pay. In the same breath not only

has it affected Jamaica and its Diaspora, or the Caribbean region but places such as United States

of America and Armenia.1

To conclude this review, based on the researches that were conducted, it revealed that

such a move requires a strategic approach. Researches purported that the removal of user fees in

the public health system generally had positive effects on access. However, there is the need for

policymakers to mobilise resources to meet the anticipated increases in demand. This may call
1 Articles and sources that have been reviewed or mentioned can be found it the appendices.

7|Page
for leaders to hold consultation with key stakeholders, and monitor and evaluate change. If more

thought is placed into it and it is revamped effectively then we may be able to see the true results of

this policy should be positive.

I cannot tell if this literature review makes sense since you have not outline any aims.

8|Page
 Data Collection Sources

To be able to conduct this research, the researcher utilized both primary and secondary

sources to collect data. The researcher, however, decided to take a more primary, quantitative

approach in investigating how the no user fee policy implemented affects the quality of health

care offered in the Kingston 4 area and to what extent. So, information was gathered by the using

questionnaires and was backed up with that of a few credible secondary sources. Hence, the

primary source used was a questionnaire and the secondary sources were information cited from

relevant books, news reports and newspaper articles on this particular topic.

Firstly, questionnaire is a data collection method that is used to collect data by issuing a list

of questions with targeted or closed-ended responses. The main reasons for selecting this method

of data collection, is that it can be used in numerous ways, such as:

It gives a more standardized response.

It yields more genuine responses due to guaranteed anonymity.

It has the ability to collect a large number of data in a short period of time.

For easy comparative analysis purposes.

Moreover, it is less time consuming than any other method. The questionnaire consisted of only

20 questions in which 19 of them were closed-ended making it easier to quantify and only 1 was

open-ended giving the respondents a chance express their view on the topic. Approximately 20

questionnaires were successfully completed out of the 25 intended; they were distributed by the

researcher to both workers and patients at the KPH health facility.

Lastly, the secondary sources may not have been used as the major data collection

method but it played a very integral role in putting it together as they were able to cover areas of

9|Page
 the research that could not be covered by the questionnaire. Books are used as a data collection

method as it collects recorded and printed data; it was used by the researcher to collect data from

recognized, credible sources that are considered to be reliable data. News reports and newspaper

articles are used as a data collection method as it collects data that are published by recognized news

outlet or media. They were used in this study to collect information that was published by the most

reliable source of news networks in Jamaica.

For the presentation of data each diagram must be on a separate page. Also donuts are not accepted.

Also I cannot correct from the data presentation onwards because I dont know what your aims are.

10 | P a g e
 Presentation of Data

How long have you been attending this health

facility?

5 and over
Time (years)

3 -- 4

1 -- 2

<1

0%
10%
20%
30%
Respondents (%) 40%

Figure 1: Bar graph showing how long the respondents have been attending the Kingston Public

Hospital health facility

How would you describe the wait time before seeing a doctor?

Time Period Number of Respondents (%)

< 1 hour 20

2 - 3 hours 50

4 - 5 hours 20

> 5 hours 10

Table 1: Table showing the respondents wait time before seeing a doctor

11 | P a g e
 How would you rate the condition of the facility and
medical equipments used?

Very Good
Poor 10%
10%

Good
15%

Average
65%

Figure 2: Pie Chart showing how the respondents rate the condition of the facility at KPH and

medical equipments used

Have you ever used a private health care service?

Yes
40%

No
60%

Figure 3: Pie Chart showing if the respondents have ever used a private health care service

12 | P a g e
On a scale of 1 to 5, with 1 being extremely poor and 5 being excellent, how
would you rate the health services offered since the implementation of the no
user fee policy compared to previous times?
Condition Number of Respondents

1) Excellent 2

2) Very Good 2

3) Average 5

4) Poor 7

5) Extremely Poor 4

Table 2: Table showing how the respondents rated the health services offered since the

implementation of the no user fee policy

How would you rate the quality of the service offered at the
Kingston Public Hospital versus that offered at private
70
medical facilities?
60
% of Respondents

50
40
30
20
10
0
Very
Good Good Average Poor
Quality of health care and
10 30 40 20
service offered at KPH
Quality of health care and
service offered at Private 40 30 25 5
Health Clinics

Figure 4: Stacked Column graph showing how the respondents rated the quality of care and

services offered at private medical facilities versus that offered at KPH

13 | P a g e
 Which measure would be best suited to cater for
citizens and to reduce the strain of the economy?

60
% of Respondents

40

20

0
Re-implement Offer free health Subsidize
user fees care to only the medication or
elderly and doctor vist
Responses children

Figure 5: Column graph showing the measure chosen by the respondents that would be best

suited to cater for citizens and reduce the strain of the economy

Since the government has implemented a free health care

policy; do you believe that this system affects the quality of
health care offered at health institutions?

No
30%

Yes
70%

Figure 6: Pie Chart showing respondents view on if implementation of the free health care

policy affects the quality of health care offered at health institutions

14 | P a g e
 Which would you prefer to go, to seek medical
assistance?
None

Health Clinic

General Hospital

Family Doctor

0% 10% 20% 30% 40% 50%

% of Respondents

Figure 7: Bar Graph showing the respondents preferred place to go to seek medical assistance

Do you think the no user fee policy should be

abolished?

40%
Yes No
1st Qtr 2nd Qtr 3rd Qtr

60%

Figure 8: Doughnut showing the percentage of respondents and their choice on whether the no

user fee policy should be abolished or not

15 | P a g e
 Which would you prefer to seek medical assistance?

Family Doctor

General Hospital

Health Clinic

None

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

% of respondents

Figure 7: Bar Graph showing the respondents preferred place to go to seek medical assistance

Sales

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

Which would you prefer to seek medical assistance Column1
 Analysis of Data

Figure 1, drafted from question 5, illustrated the period of time the respondents have been

utilising the Kingston Public Hospital (KPH) health facility. The results showed that 40% of the

respondents said that they have been attending the facility for 3 to 4 years, 35% saying 5 years and

over and the remaining 35% was either attending the facility for less than a year or for 1 to 2 years

(10% and 15% respectively).

Table 1 was in response to question 10; it showed the period of time in which the

respondents had to wait before seeing a doctor at KPH. The study revealed that 50% of the

respondents had to wait for 2 to 3 hours, 10% for over 5 hours, 20% waited for less than an hour

and correspondingly 4 to 5 hours.

Figure 2 which came from question 6, showed how the respondents rated the condition of

the facility at KPH and the medical equipments used. The results showed that 65% of the

respondents rated the conditions of the facility and the medical equipments used being average,

15% rated it good, 10% rated both poor and correspondingly very good.

Figure 3 was in response to question 11; it showed whether or not the respondents have

ever used a private health care service. The results showed that only 40% of the respondents

have ever used private health care while the remaining 60% have not.

Table 2 drafted from question 20, showed how the respondents rated the health services

offered since the implementation of the no user fee policy. The results highlighted that out of a total

of 20 respondents, 2 rated it excellent and correspondingly very good, 5 rated it average, 7 rated it

poor and 4 persons rated it extremely poor.

16 | P a g e
 Figure 4 drafted from questions 7 and 12, illustrated how the respondents rated the

quality of care and services offered at private medical facilities when compared to that offered at

the Kingston Public Hospital. The line graph depicted that 40% rated the private health care

services to be very good, 30% rated it good, 25% average and the remaining 5% poor. Whereas,

the health care services at KPH was found to be average by 40% of the respondents, 30%

considered it to be good, 20% poor and 10% very good. Based on these responses, the trend that

can be seen indicates that the majority of the respondents have a higher or more positive rating

for the quality of care and services offered at private health facilities. The trend is that as the

rating for the private health facilities decreases (from very good to poor); that for the KPH

increases up to average.

Figure 5 was in response to question 17; it showed which measure the respondents

considered as the best suited to cater for citizens and reduce the strain of the economy. The graph

revealed that 50% of the respondents would prefer if the no-user fee was offered to only the

children and the elderly, 40% would rather if medications or doctor visits were subsidized and the

remaining 10% would want for the user fees to be re-implemented.

Figure 6 which came from question 15, showed the respondents view on whether or not the

implementation of the free health care policy affected the quality of health care offered at health

institutions. The results depicted that 70% of the respondents indicated that yes the policy has

affected the quality of care offered while 30% said no.

Figure 7 which came from question 13, showed where the respondents preferred to seek

medical assistance. When asked the preferred place to go seek medical assistance, 40% of the

respondents said their family doctor, 30% said the general hospital, 20% would rather go to the

health clinic and 10% would not go to any and just stay home and use home remedy.

17 | P a g e
 Figure 8 drafted from question 16, speaks to whether or not the respondents believe the no

user fee policy should be abolished. While 60% of the respondents were in agreement to the

abolition of the policy, 40% was in opposition.

18 | P a g e
 Discussion of Findings

Through this research, it was discovered that majority of the respondents considered the

quality of care and services offered at the Kingston Public Hospital (KPH) to be average, as well

as the facilities and the medical equipments used in the various procedures. This is somewhat

commendable that they are receiving health care under satisfactory circumstances. Meanwhile,

the minority of responses were geared towards both extremes, that is, very good or poor. This

mere contentment with the infrastructure may be a possible reason as to why they choose to

continue utilizing public health services rather than private over the years. However, the findings

yielded by the researcher depicts a complete twist to what was discussed earlier from the variety

of articles and other illustrious forms of complaints lodged by citizens right across the island.

They expressed the vast number of discontentment that the citizens have to endure just to get

proper health care.

Similarly to the sources of literature reviewed earlier, most of the respondents have

shared comparable sentiments as they expressed how they have to wait for a long, 2 to 3 hours

before being attended to. When a few of the workers at the facility were asked about the long

lines (hence, long wait time period), it was made to understand that this has been the case since

the implementation of the no user fee policy in 2008. Since then there have been shortage of

workers, medical supplies and equipments as funds allocated to the sector have been strained

excessively to cover all the expenses of this sector. These arguments can be supported by the

Health Access Study (CaPRI, 2013), which profoundly stated that since its implementation, it

has negatively affected the health sector in areas such as staffing, medical supply stocks and

waiting times due to the loss of financial resources; which was coincidentally found in this

19 | P a g e
research. It is also supported by the journal (Healthcare in Jamaica, 2012), in which the Diaspora

voiced its concerns reiterating the agony faced by the returnee residents towards the long lines.

Hence, this argument stands firm.

Subsequently, the data yielded that most of the respondents have never used private

health services. Notably, more persons considered health care to be better in the private health

sector rather than public health services. As a result, this implies that other factors may play a

role in the low usage of the private health services such as affordability and proximity.

Additionally, a significantly higher number of individuals thought that public health care was

poor as opposed to that of the private health sector. In spite of this significance, many would

question why are they enduring these hardships by keep going to KPH over the years, the simple

fact is that they just cannot afford to pay the fees at the private health care facilities; hence why

they continue to use it. This is somewhat supported in the literature review (paragraph 2), where

the IMF and World Bank lobbied for a pro-market reform as there were in high signs injustice as

patients were turned away because of the same reason them not being able to afford it. However

in recent times health care have become accessible to all but if you seek high quality treatment

that would have to be paid for and maybe at cost unaffordable by the social groups. This act of

classism was what was being avoided but unknowingly ran right back into it.

Amidst the cry for more facilities to be built to attend to the constantly growing

population, it was the general view of the respondents that before the government can consider

building new facilities, it should seek to circumspectly evaluate the current ones and then further

developments can take place, in order to upgrade them to their full potentials, if the needs be.

Thereafter, it can be concluded if there really is a need for new health facilities to be built. Also,

in the same way the view aroused that how can there be any construction of new infrastructures

20 | P a g e
when there is hardly any funds to support the current ones, along with its other stipulated

responsibilities. In general, the call is for the government to take a systematic approach to this

policy in going forward.

In addition to just simply investigating the effect of the no user fee policy on the quality

of healthcare, alternative measures which could possibly alleviate some of the issues raised were

also sought. The results highlighted that the majority of the respondents would prefer a decision

be made in which the no user fee policy is applied to the vulnerable socials groups (children,

elderly and special needs). This would in turn, ensure that those who have more of a challenge in

accessing good health care will be able to utilize these services when necessary. On the same

hand, fewer people stated they would prefer if the medications and visitation fees were

subsidized. Only a very few of the respondents has expressed their desires for the user fees to be

re-implemented. Supporting evidence for the alternative measures suggested, can be seen in the

literature review (paragraph 7) where some of these same suggestions forms a part of the health

reform system in Barbados, which has a very successful health sector. So if some of these

measures are implemented in Jamaica as well, the health sector may begin to thrive and show

more positive results and reflect in the type and quality of service received.

Correspondingly, the findings also depicted a slightly significant majority of the

respondents profoundly indicating that they would not want this policy to be abolished but at the

same time indicating that they are not all pleased with it. This argument was refuted as

(Cunningham, 2013) and (The Gleaner, 2016) explicitly called for the policy to be abolished as

in their eyes it is causing more harm than good. So through all this the economy plays a vital role

in the development of a country and in this case specifically the health sector. However, outside

of the part the economy has to play in this development, more thoughtful and strategized

21 | P a g e
planning and by extension proper management has it be instituted for further growth and

development to occur through this sector as was indicated latently by the findings.

By the findings, it can be therefore said that the stated purpose of the research was

achieve as the true effects that the policy has on the quality of health care offered in the clinics

(specifically KPH) was shown. Also, as a result, it can be implied that persons were becoming

more educated and sensitized as to the role the economy plays on the health sector, as well, the

value it places on it, through this study.

22 | P a g e
 Conclusion, Limitations and Recommendations

The researcher has discovered that the patients who attend the clinic at the KPH have

stated that the quality of health care received at the facilities is averaged and when compared to

the quality of care offered at private health facilities, which was stated to be above average.

Furthermore the patients believe that services offered to them can much be improved through

medical officials adequately allocating time to each patient to carefully attend to the; as the time

in which services are offered and the wait time are usually one of the major turnoffs. It can

further be concluded that the free health policy is a major contributing factor to the many issues

and downfalls currently affecting the sector in terms of the quality of care and services offered at

facilities.

Limitations

There are a variety of factors that may have resulted in the findings being limited. The

sources of literature used to gather data on this area may have been outdated, as some of the

publications were dated as much at 5 years old. Another is that the main instrument of data

collection used, that is, the Questionnaire- was also a limiting factor as it restricted the researcher

to view the issue at a certain scope. The sample size used in the study was relatively small

preventing the researcher from getting a more generalized finding; which may have resulted in

the results being limited.

You must discuss at least four limitations each in a separate
paregraph.

23 | P a g e
 Recommendations

It is recommended that the Ministry of Health increases its service delivery capacity to

keep up with the high levels of utilisation, which will seek to lessen lengthy wait periods. This

can possibly be done by implementing a number system or an appointment system. This method

may alleviate some of the current challenges faced as it would ensure that things a done on a

timely basis and also will avoid patient being there for unnecessarily long hours. Also, a further

and more generalized research should be conducted on this topic; as there may be other factors

affecting the health system that could also be investigated to arrive at a more detailed conclusion.

Lastly, it is recommended that seeking donations from private sector to aid in the financing

poorly maintained facilities, as it would beneficially fund the improvement of these facilities.

You must discuss at least three recommendations each in a

separate paragraph.

24 | P a g e
The bibliography must not be written in bullets it must be written in alphabetical order based on the authors
surnames. Also please pay attention to the specifications of the APA style such as the indentation of the second and
third lines of each reference.

Bibliography
CaPRI. (2013, May). CaPRI Caribbean. Retrieved March 2016, from

http://www.capricaribbean.com/sites/default/files/public/documents/report/no_user_fee_p

olicy_in_public_hospitals_in_jamaica.pdf

Cunningham, A. (2013). Free Health Fallout - Too Much Freeness - No-User-Fee Policy

Worsening Poor Service - CaPRI Study. The Gleaner. Retrieved February 12, 2016

Fernholz, T. (2010). US Healthcare reform: the economic effect. Retrieved February 12,

2016

(n.d.). Health sector in Armenia and the fee-waiver program. Armenia. Retrieved

February 12, 2016, from http://www.who.int/management/effectsoffeewaiverarmenia.pdf

Healthcare in Jamaica. (2012). West Indian Medical Journal.

Healthcare in the Caribbean. (2016, March). Retrieved from Caribbean Buying Guide:

http://www.caribbeanbuyingguide.com/content/caribbean-healthcare-caribbbean

Hibbert, K. (2015). Doctors blame lack of resources for poor health care; Ministry to

investigate supply problems at hospitals. Jamaica Observer.

The Gleaner. (2016, January 5). No User Fee must go!!!! Clarendon Leaders want

drastic Change 2016. Jamaica Gleaner. Retrieved March 2016, from http://jamaica-

gleaner.com/article/news/20160105/no-user-fee-must-go-clarendon-leaders-want-drastic-

changes-2016

The Guardian. (2011, September). Healthcare System still deficient.

25 | P a g e
26 | P a g e
 Questionnaire

Instructions: Please answer the following questions to the best of your ability by simply

placing a tick () in the box beside your answer and by writing your answer(s) on the line(s)

provided at the appropriate time Please be reminded that any information is kept confidential

and your identity is not required.

1. Gender:

Male Female

2. Age Group:

16-30 31-50 51 & over

3. Which social class do you belong?

Upper Class Middle Class Lower Class

4. a) Are you a frequent patient of the Kingston Public Hospital (KPH)?

Yes No

b) If yes, how often?

1 - 2 times a week Every 2 weeks

Once a month Very rare

27 | P a g e
5. How long have you been attending this health facility?

Under a year 1-2 years 3-4 years 5 years and over

6. How would you rate the condition of the facility and medical equipments used?

Very Good Good Average Poor

7. How would you rate the quality of the service offered at the Kingston Public Hospital?

Very Good Good Average Poor

8. How would you rate the administration of medicines at KPH?

Very Good Good Average Poor

9. How were you treated by the medical officials or the workers at the facility?

Very Good Good Average Poor

10. How would you describe the wait time before seeing a doctor?

Less than an hour 2 - 3 hours 4 - 5 hours Over 5 hours

11. Have you ever used a private health care service?

Yes No

12. How would you rate the quality of care and services at the private medical facilities?

Very Good Good Average Poor

28 | P a g e
13. Which would you prefer to go, to seek medical assistance?

Family Doctor Health Clinic General Hospital

None of the above, stay home and use home remedy

14. What are some of the faults of public health care that would motivate you to attend

private health clinics?

Long waiting time Limited attention given

Inadequate resources Poor customer service

15. Since the government has implemented a free health care policy; do you believe that

this system affects the quality of health care offered at health institutions?

Yes No

16. Do you think the no user fee policy should be abolished?

Yes No

17. Which measure would be best suited to cater for citizens and to reduce the strain of the

economy?

Re-implement user fees

Offer free health care to only the elderly and children

Subsidize medication or doctor visit

29 | P a g e
 18. In your opinion, do you think that the government should build more health

infrastructures and why?

________________________________________________________________________

________________________________________________________________________

_______________________________________________________________________
19. On a scale of 1 to 4, with 1 being the least and 4 being the most, Rank the following
factors on how they affect the quality of health care offered at KPH since the
implementation of the no user fee policy compared?

Lack of technology Lack of Resources

Poor Management Poor trained health professionals

20. On a scale of 1 to 5, with 1 being extremely poor and 5 being excellent, how would you
rate the health services offered since the implementation of the no user fee policy
compared to previous times?

1- Excellent 2- Very Good 3- Average

4- Poor 5- Extremely Poor

30 | P a g e
 Articles

No User Fee Policy in Public Hospitals in

Jamaica

Date Published: May 2013

Date Retrieved: March 2016
Document Author(s): CaPRI

Document link:
http://www.capricaribbean.com/sites/default/files/public/documents/report/no_user_fee_policy_i
n_public_hospitals_in_jamaica.pdf

__________________________________________________________

West Indian Medical Journal

Print version ISSN 0043-3144

West Indian med. j. vol.61 no.2 Mona Mar. 2012

Healthcare in Jamaica

Quality medical care in Jamaica is one of the prime concerns of many returnees and
residents. The good news is healthcare in Jamaica is free to all citizens and legal residents at
government hospitals and clinics.
This includes prescription drugs, however, its not all good, one of the drawbacks to free
health care is the very long lines and poor service, with a no appointment booking system
accepted by the physicians. There have been stories in the newspaper of people going to the

31 | P a g e
hospital early in the morning and leaving late in the day not having seen a doctor - the truth is
this is now very common, even for the very sick, the system simply cannot cope with the volume or
demand.
Prescriptions are not easy to obtain. It is not uncommon to see 20 - 30 people gathered at
a hospital pharmacy two hours prior to its opening. The closer to the opening time, the more
people congregate to receive the medicine they need and probably cant afford. Its not unusual
to hear that patients are turned away because of either a lack of supply or a drug the pharmacy
doesnt stock. If the person really needs an unavailable drug they must go to a public drugstore
and pay for it or do without.
Private doctors and clinics are widely available as long as you have the funds or
insurance to cover the cost, these can be of the very highest standards but can be very expensive,
and even here long queues can be quite normal. Many leave treatment until they can be off
island, but this is of course not always possible.
Medical insurance is available from several different companies. However, health
insurance CANNOT be purchased if you are 65 years or older unless you have been previously
enrolled before your 65th birthday in a Jamaican plan with some operators and insurance
companies.

- See more at: http://coming-to-jamaica.com/?page_id=61#sthash.Okad8xp9.dpuf

__________________________________________________________

Free Health Fallout - Too Much Freeness - No-User-Fee Policy

Worsening Poor Service - CaPRI Study

Published: Tuesday | June 11, 2013

Retreived: February 12, 2016

The quality of service in Jamaica's public hospitals has got worse since the no-user-fee policy
was introduced five years ago. It is now ineffective and inefficient, with nurses and doctors
displaying an apathetic attitude towards patients and their general duties.

32 | P a g e
So said the findings in a review of the system by the Caribbean Policy Research Institute
(CaPRI).

Conducting the study between April 15 and May 20 across all 14 parishes, CaPRI said it was
also evident that the service has not only got progressively worse but also exceedingly slow.
Compounding that is the increased patient-to-health-care worker ratio and insufficient
medication and medical supplies to meet the demand.

"The quality of service would be better and faster if people were paying. Doctors and nurses
would have a better attitude and the hospitals would operate more efficiently," noted some of the
respondents who were interviewed.

"The hospitals just cannot afford the luxury of free health care and the Government can't afford
to foot the bill alone. It only results in an abuse of the system and overwork the health-care
workers. When it is free, doctors and nurses display a poor attitude."

Seeking to investigate the effect of the no-user-fee policy on health services in Jamaica and to
explore the scope for returning to a fee-paying system in the future, the study noted that several
persons were calling for the reintroduction of user fees on the grounds that free health care was
not sustainable. Both health-care workers and patients were of the view that 'those who can pay,
should'.

"It needs cash to care and this will help to greatly improve the system. People should
contribute to their own health care, as it's very costly," those surveyed stated.

CaPRI has recommended that if the policy is to be maintained, it must be twinned with a
package of reforms that address longer term health-systems issues, in particular, adequate
financial resources, health worker availability and performance and drug supply chain
management.

33 | P a g e
 "It is worth studying the impact that the policy has had on the overall 'health of the
nation' and whether or not there has been an increase in preventative health care," CaPRI
concluded.

As part of its commitment to universal access to health care, in 2008 the Bruce Golding-
led administration removed user fees for services at public hospitals, except the University
Hospital of the West Indies. This was a significant departure from a policy of user fee
reintroduced in 1984.

The Government is hosting a series of public consultations during which members of the
public are allowed to propose ideas to remedy the woes in the country's health-care system.

The CaPRI study was carried out with the aid of grants from the International Development
Research Centre in Ottawa, Canada, The Gleaner Company Limited and the National Health
Fund.

_________________________________________________________

Healthcare system still deficient

Published: September 30, 2011

There seems to be no end to the stories of the national public health system failing
to deliver quality healthcare to patients who go there for services. The most recent
incident involves the death of a 33-year-old woman at the San Fernando General Hospital.

34 | P a g e
She reportedly died after undergoing a C-section at the southern hospital. It is too early to
say definitively whether or not the hospital care system was deficient and hence the death of
the woman. However, because of what is generally perceived as the almost institutional
unprofessional performance of our public health institutions, the assumption could be
widespread that the womans death could have been avoided if the system had performed up
to an internationally accepted standard.
Without seeking to do a detailed review of questionable deaths over the last ten
years, it is public knowledge they have ranged through patients, many of them children,
not being promptly or adequately treated, mothers dying during and after child birth,
failure to accurately diagnose diseases and therefore give proper treatment, the unsanitary
state of national health institutions, non-functioning equipment, the absence of basic
equipment expected of a country as wealthy as Trinidad and Tobago. The comment is
made about the relative wealth of T&T for the purpose of pointing out that this is not
some backwater country without a capacity to provide its citizens with a high standard of
basic healthcare. Moreover, a large percentage of government budgeting over the period
has gone into the health system to provide the physical facilities, inclusive of buildings
and conditions on the wards of the hospitals and the medications required.
With regard to medical care, the cost of government scholarships, the funding of the
medical faculties of the University of the West Indies, the salaries to medical staff have run
into hundreds of millions of dollars and yet we receive reports of unprofessional treatment of
patients. What is more, this is a country with a long history of exceptional medical
professionals, doctors, nurses and researchers who have had outstanding
international professional careers. The importance of that is that young medical
professionals are not starting from scratch; they have a base, a tradition and examples of
professionalism to follow as they strive for excellence. One area of healthcare that has
often been called into question is the administration of the public health institutions. But
here too there has been quite an amount of government expenditure in producing
management experts and, undoubtedly, there will be more in the specialist field of
healthcare management.
Perhaps this is an area for renewed discussion and attention by the Government.
Here the assumption cannot be that because someone emerges as an excellent doctor or

35 | P a g e
nurse, he or she automatically qualifies to be a health administrator. One result of the
questions surrounding the quality of public health services has been the reality of people,
who have the wherewithal, going abroad for basic healthcare which any country of the
stature of T&T should be able to provide. Fact is that many such people have lost, or indeed
never had, confidence in the system.
Then there is the view that citizens wanting to get the best of what is on offer at the
hospitals and public health centres must engage in some form of corrupt activity, such as bribing
an official. The relatively new Minister of Health must challenge himself to bring resolution to
problems of the healthcare system before he leaves office.
________________________________________________________

Health sector in Armenia and the fee-waiver program

Dated: February 12, 2016

Link: http://www.who.int/management/effectsoffeewaiverarmenia.pdf

This section describes the evolution of the health sector during the nineties and the
implications in terms of access to health care, especially among the poor and other vulnerable
populations. The transition process in Armenia involved the health sector in at least two
dimensions. First, the overall decrease in public expenditures in health care during the early
nineties affected the number of personnel, quality of services and the maintenance of the existing
infrastructure. Even though the fall of real spending in social areas after independence was
reversed in the late nineties, important effects on the supply quality of health services and on the
demand for health care were observed. The declining quality of services associated with lower
wages, lack of drugs and deteriorated infrastructure was accompanied by a significant decline in
the number of patients and increased informal payments.
A second dimension is the market-oriented reform in the health sector, which involved a
decentralization process and privatizations of some components of the system. Hospitals and
polyclinics were converted into semi-private enterprises and the management of health care
providers was decentralized allowing them to fix their health service prices, choose their mix

36 | P a g e
between medical and administrative personnel, and allocate resources accordingly. In 1993 state
health care institutions became state health enterprises, or semi-independent units that could
generate their own revenues parallel to state budget financing. In 1995 hospitals and polyclinics
were permitted to provide private services in addition to state funded ones, providing them
additional autonomy with self-decision on staffing (World Bank 2002a). The separation between
health care delivery and financing was established through the creation of the State Health
Agency (SHA) in 1998, responsible for purchasing services to providers (hospitals). In order to
contract out services a Basic Benefit Package was established.
The changes during the nineties represented the actual elimination of former free
universal health care coverage since those allowed providers to generate their own revenues
through OOP. As a result, the increased incidence of out-of-pocket expenditures -- and even
worse, that of informal payments to medical and administrative staff -- resulted in decreased
health care utilization, especially among the poor. To respond, the government established a
program that provided free of charge medical services based on two eligibility conditions:
(i) the patient belongs to some vulnerable socio-economic categories; or
(ii) the medical care is qualified as urgent by the medical staff.
The definition of the vulnerable groups actually corresponded to the system of categorical
social assistance benefits inherited from the former Soviet Union. All costs of services (not
including medications) under the program for the Vulnerable Population are covered by the
government and expected not to exceed 30 percent of the providers total annual budget. All
other interventions are expected to be cover by the resources generated by the providers.

__________________________________________________________

US Healthcare reform: the economic effect

Publisher by: Tim Fernholz

Published: March 22, 2010 (Last modified: December 31, 2015 )
Retrieved- February 12, 2016

37 | P a g e
Main Point:
While the healthcare bill is moderate in ambition and scope, it will have far-reaching effects in
the public and private sector.

Aside from Democratic cheers, there was no immediate sign that the passage of
healthcare reform last night will have a major impact. (No, the socialist utopia has not yet
begun.) But, while the bill is moderate in ambition and scope, it will have far-reaching, and, if
you believe non-partisan economists, ultimately beneficial effects on the economy, in both the
public and the private sector.
Perhaps most important in Washington is the budget picture. Democrats wanted to
expand healthcare coverage to as much of the population as they could, but insisted on making
sure the bill was deficit neutral. In fact, according to the Congressional Budget Office, the bill
will reduce the deficit $143bn over 10 years, and could reduce the budget deficit by one-half
percent of gross domestic product - a little over a trillion dollars - in the next decade. Further,
the CBO has a history of underestimating healthcare cost savings, so the numbers could improve
from there.
The bill will also act to lower the overall cost of healthcare through a series of public
policy mechanisms within Medicare and Medicaid, ranging from commissions to determine how
best to reimburse doctors to funding for research to find the cheapest, most effective medical
procedures.
It also helps shape the private market with insurance exchanges that improve
competition, taxes some expensive health plans to force insurers and employers to negotiate
better care, along with other, more prosaic measures - investments in information technology
and prevention - to "bend the cost curve" down. CBO believes that the plan will "substantially
reduce the growth of Medicare's payment rates for most services" and "substantially reduce the
cost of purchasing [health coverage]" for families.
The bill will also have an effect on the labour market. If it helps cut costs and reduce
premiums, we could see growth in wages for working people. A variety of academic studies have
identified a connection between stagnant wages and increasing insurance premiums; reversing
that trend could help drive up salaries. Further, and crucially, the White House Council of
Economic Advisers believes the bill can create some 320,000 new jobs, increase GDP growth by

38 | P a g e
 4% over the next 20 years, and increase average family income by $6,800 in the same period.
Healthcare economists David Cutler and Neeraj Sood think the bill could create between 250,000
and 400,000 jobs a year over the next decade.
The bill's proponents also point out that it will help small businesses with tax credits that
will ease the costs of providing health insurance, and will spur entrepreneurialism by eliminating
"job lock" - when a person avoids pursuing new opportunities in order to protect their employer-
sponsored healthcare coverage.
These are the arguments that reformers have been making about the bill for ages. While some of the Republican criticism is
sheer demagoguery, and other critiques mostly procedural hand-waving, some have made points about concern that Congress
won't follow through on
necessary future steps to preserve the savings in the bill. However, as the Centre on Budget and Policy Priorities has
demonstrated, Congress has historically demonstrated a willingness to
impose these savings in deficit reduction legislation from 1990, 1993, 1997 and in 2005.
Now that the bill is passed, we'll have the empirical evidence to see whose claims about the bill turn out to be true. Much like
President Obama's other signature legislative victory, last year's stimulus package, we'll likely find that the data supports
reformers' promises.
And did I mention, the bill covers some 31 million Americans who didn't have health insurance before? It's not all dollars and
cents, you know.

__________________________________________________________

39 | P a g e