Fentoncare is not Obamacare

by Dr Yitades Gebre

As Jamaica struggles with insufficient economic growth, increasing demand for chronic diseases care, challenges of maternal death, and treatment demand for HIV and AIDS, exploring universal health coverage is urgently needed more than ever.

Part of the renewed health policy dialogue in Jamaica has been the review of user-fee exemption policy for health services. It is indeed very healthy to have such public-health policy discussion while looking for alternatives to address this complex intervention.

Several low- and middle-income countries, specifically in Africa, have removed user fees for health services in order to improve accessibility to health care for the vulnerable. Since 2001, about 17 countries have implemented such policies.

James C., and colleagues in the 2006 article 'To Retain or Remove User Fees' writes: "The questioning in these countries, however, is not anymore whether to retain or remove this exemption but rather how best to accompany governments pursuing this objectives."

understanding the 'why'

First, I believe that it is critically important to understand why governments institute user-fee exemptions, how they are supposed to work, what outcomes are expected, what barriers to health-care access and equity need to be determined.

Second, we need to analyse carefully both the intended and unintended impact of the reform.

Third, what other policy options were assessed prior to the user-fee exemptions.

One key strategic feature of the Jamaica health-care system in the last two decades has been "good health at low cost". Governments have tried to invest in accessible and affordable community-oriented services (primary health care/drugs-for-elderly programme) and improve the pillars of a health system - its workforce (nursing schools), financing programme (NHF), governance, supply systems, infrastructure, and so on.

It should also be noted that despite this effort over the years, with increasing population and ageing, demand for quality services, occurrence of new and emerging diseases like HIV, health-care progress has its own obstacles and limitations.

According to some published studies, the removal of user fees usually increases utilisation rates of health services (at least, in the short term). However, it does not automatically improve health and increase financial protection. To reach those goals, the policy must be well designed and properly implemented.

Hence, the current debate on removing or retaining user fee for health services in Jamaica should be framed based on the policy objectives, priorities identified, context, stakeholder support, implementers' attitude and the technical leadership by relevant officials at the outset of implementing the stated policy.

a comprehensive approach

In 2010, the World Health Organisaton director general, recognising the global economic downturn and rising health-care cost, advised countries to improve efficiency, reduce waste and explore the path to universal coverage and not to solely depend on direct payment, including user fees.

We want our governments to take comprehensive and multisectoral approaches to ensure better health outcomes are achieved for all citizens of Jamaica. The Government needs to diversify the source of funding to reduce the reliance on direct payment by promoting prepayment and pooling and to use funds more efficiently and equitably.

Simply choosing from a menu of options, or improving what has worked in other setting, will not be sufficient. A Jamaican health-financing strategy is needed to pursue universal health coverage. 'Fentoncare' is not 'Obamacare'! Each country has different choice how to raise revenues, how to pool them', and how to offer the services.

In all this debate, it is important to remember the grandmother in Frankfield, Clarendon, who needs cataract surgery; the unemployed mother-of-two pregnant woman with HIV in St James; the middle-age male store manager in Spanish Town with diabetes; and the five-year-old child with asthma in Kingston.

Our health policy and health care-financing policy is a means to an end, not an end in itself.

Dr Yitades Gebre, former senior medical officer in Jamaica's Ministry of Health, is an adviser for the Pan American Health Organisation and World Health Organisation. Email feedback to columns@gleanerjm.com.