Introduction and Purpose of Research

In 2008, the governing party, Jamaica Labour Party (JLP), implemented

a no user fee policy for healthcare. With this, a myriad of benefits, question
and shortcoming have presented themselves.
Heath care, in most developing countries such as Jamaica, is a serious
cause for concern. This is due to the lack of resources such as staff and
proper equipment and mismanagement of the little we have. The main
reason for this is funding; the lack thereof. Many critics have questioned the
feasibility of the free healthcare and its sustainability in Jamaica. With the
implementation of free healthcare, is Jamaica setting itself up for improved
services in this sector? and With Jamaicas current economy, how will this
really be paid for? are a few of the questions raised by the sceptics who
thought the ideology beneath this proposal was fundamentally flawed. (JIS,
2008)
However the aforementioned concerns were quietly by the health
minister later in 2009 that the benefits from the no user fee policy outweigh
the sacrifices. Now, after 6 years and a change of governments, the policy is
still in place. How has this policy really benefit Jamaicans, especially those of
the lower echelons of society? This and aforementioned questions drove me
to select the subtheme: Healthcare and economy under the theme:
Health derived the focus of my study to be: Investigating the benefits and

shortcomings of the no-user fee policy (free healthcare) for the members of
the communities of Lakes Pen and Lime Tree.
The research is aimed at investigating the following:

What percentage of the population of these communities uses this

free healthcare?
Which social and economic tiers utilize this no user fee policy

mostly?
How often are these services utilized?
How beneficial have the services provided been?
What are the problems faced at health centres?

It is important that the country and its citizens continuously assess and
redefine certain policies in order to be not only proactive but to also move
forward. This research bears significant educational value mainly because as
future leaders we have the tasks to evaluate the good that our predecessor
has done and build upon and to remove all aspects of the past that worked
only to our demise. This research is geared towards addressing the issue of
whether or not this is one such policy.
Definition of Key Terms:
Echelon, as defined by the Oxford English dictionary, is a level or rank in
society, a social class
User fee, as define by dictionary.com, is a charge amassed when a person
uses a specific service. A business which makes use of this is banks. The lack
of user fee therefore implies that this fee is not paid by users and the service
can be said to be free.

Economy, as defined the Oxford English Dictionary, is a system consisting of

production, distribution and trade and lastly the consumption of goods and
services within a given area.

Literature Review

The need for healthcare worldwide has increased tremendously with

the increasing global population. We see since the industrial revolution the
world's population has approximately double. In addition, with advancements
in transportation

the world is no longer separated masses of land

global village in which

each

country bears significant weight on

but a
global

stability, however some more than others. With these truths being present,
the transfer of diseases has become just as easy as making a phone call and
the need for readily available and affordable healthcare and medication has
been on the increase exponentially. (Fuchs, 2000)
Free healthcare provides an avenue for all citizens to achieve or gain
an acceptable level of healthcare. It may also have negative spin offs where
due to the increase of the demand and usage of facilities will cause the rapid
diminishing of the quality of healthcare facilities. This source gave
3

background information which was useful in the development of the research

plan and ideas.
A number of shortcomings were noticed throughout the planning and
implementation of the policy and documented via a research journal. These
are: cost of healthcare not aligned with patient outcomes; primarily because
of the lack of a patient-focused approach to the delivery of health services,
inadequate budgetary support for the MOH which has resulted in poorly
staffed and poorly stocked healthcare facilities and underfunding resulting in
a deterioration of the Jamaican health sectors and finally, a dysfunctional
health reform process (regionalization) which has demonstrated: ageing and
poorly

maintained

medical

equipment

and

physical

plants,

poor

implementation of changes, including the no-user-fee policy and lack of

dialogue and participation in the decision-making processes across the
sector. (De La Haye, 2011) The journal presented a well of knowledge
surrounding the operations involved in implementing this policy.
The source also highlighted plans designed to increase the efficiency of
the policy which should have being set in place. For example: increased staff
at specific hospital which often see patients waiting for unbearable times due
to the high demand of the service provided by the hospitals and also the
purchasing and implementation of several
million

US dollars.

equipment valued at over 2.7

These sources were useful in giving background

information on the research and also in the development of the research

objectives.
4

According to a journal there are two major concerns about the policy
implemented originally by the JLP and perpetuated by the PNP. These are
how much of these cost exempted to users are covered by taxes and how
much do these exemptions affect the health and economic sectors of the
country? The previous cabinet after slating out the budget explained that a
portion of the budget will be directed towards this and other moneys will
come from other sources. The new governing body, PNP implemented the
same system of paying for this free healthcare but the question still remains
as how does this affect development of and the sustainability of healthcare
facilities. These fees that were formerly paid helped in the maintenance of
hospital and hospital facilities. However, they warded off members of the
lower social and financial tiers of society. (CAPRI, 2013)
The journal furthered dissected the benefits by placing statistics and
tables of the progress of the policy in several parishes especially those of a
greater population. For example: Spanish Town Public Hospital, Kingston
Public Hospital, May Pen Hospital and the Mandeville Hospital. The journal
provided statistics and graphs and in essence fuelled how I decided to do my
presentation of data further in this documentation.
Since the implementation of the policy it is reported that the poor has
benefitted tremendously by the policy and the JLP were commended for
having put it in place. Though this is true one begs to question if so much of
the countries resources should be geared towards this effort and how
medical staff, having to work long hours is affected. Many healthcare workers
5

complain about the facilities and the number of patients they offer services
to daily. There is insufficient staff and as a results worsening poor service.
(Cunningham, 2013) This article, having decided to engage in an interview,
helped me to develop my interview questions.
Hundreds of thousands of Jamaicans have benefited from the no user
fee policy over the years since its inception. As a result many sceptics have
become more confident in the choices made in relation to this concept of
free healthcare. Not only did it boost the nations health and awareness of
diseases but members of the population living with HIV/AIDS have gained
medication which would otherwise be extremely expensive to procure.
(Willis, 2013) Approximately, 86 percent of Jamaica makes use of this policy
regularly and 68 percent as their only mean of healthcare. (Henry, 2012)
However the services provided, assessed by a survey completed by CAPRI
funded by the International Development Research Centre in Ottawa,
Canada, The Gleaner Company Limited and the National Health Fund were
found to be limited and of a barely acceptable standard. It was also shown
that the majority of the patients who benefitted were asthmatics, the elderly
with

non-terminal

diseases,

and

pregnant

women

from

inner

city

communities. This provided a bench mark by which several quantifiable

information, expected to be receive, will be compared.
There remains an ongoing debate as to how the healthcare reform
surrounding the no-user fee policy affects Jamaica and what effects, both
positive and negative, does it have on the economy. Several political
6

commentators and state ministers have, over the years, engaged in cross
talk over this issue and despite the highlighting of several shortcomings the
policy is still in effect. Parliament is currently reviewing the policy to
implement a those you can pay should pay policy. This is due to the
discomfort of doctors who continue to work despite the worsening condition
to facilities, worsening pays, high inflation and fear of termination of
contracts. (Hibbert, 2015)
The topic of healthcare and its effects on the economy is by no means
exhaustive due to the constant morphing and evolution of the two sectors
with changing populations. This research will try to educate and achieve a
level of insight into the specified theme.

Data Collection Sources

A combination of primary and secondary sources was used to conduct

this research paper. Survey was the selected research method using
questionnaires as the instrument; the researcher chose a quantitative
approach. The main source of primary data therefore came from the
questionnaires which were manually distributed to 25 persons using
stratified sampling.
The questionnaire consisted of 12 questions; 10 close-ended with a
number of choices being given and 2 open-ended response questions. Each
selected individual was approached and asked whether they would be
interested in participating in the study. The time taken for an individual to
complete the questionnaire was estimated five minutes.
Questionnaires were chosen as they are concise and easy to fill out
and were also easy to administer as many can be done at a time without
face-to-face interactions. They were manually distributed because this was
cost and time effective as the communities selected were relatively small
and within close proximity of each other. Confidentiality of information is
important and questionnaires serve to facilitate this. The questionnaire
contributed to the study by obtaining quantifiable data for further analysis.
The other source of primary data came from an interview with doctor
Landel, a medical doctor at the Spanish Town Hospital, which serves the
majority of these communities healthcare needs. The interview took
approximately five minutes and was structured, consisting of only four
questions. It was used to test findings from the questionnaire and provided
8

an in depth analysis because it was extensive and involved face-to-face

interaction. Additionally, the interviewer was able to interpret verbal and
nonverbal

responses

and

thus,

make

reasonable

deductions

and

comparisons.
The secondary sources of information came in the form of internet
sources, published books, journal and magazine and newspaper articles as
well as past research. The secondary sources were used to obtain general
knowledge on the topic as well as any statistics that could support the
research. This provided several perspectives and aided in broadening insight.
Lastly, they provided a wealth of similar and contrasting views.

Presentation of Data

Questionnaire Results:

Bar Graph Showing Age Group of Respodents

11

4
2

13-25

26-40

40-55

Figure 1: Age group of respondents

10

above 55

Pie Chart Showing Gender of Respondents

Male
Female

44%
56%

Figure 2: Gender of Respondents

Bar Graph Showings Respodents Who Use Public Health Facilities

22

Respondents who use

public health facilities

Yes

No

Figure 3: Respondents who use public healthcare services

11

Bar Graph Showings Respodents Having No Alternative

18

Respondents who have no

other alternative

Yes

No

Figure 3.1: Respondents who have no other alternative

Pie Chart Showing Frequency of Visits to Public Health Facilities

12%
Never

24%

Rarely
20%

Sometimes
Often

44%

Figure 4: Frequency of visit to facilities

12

Bar Graph Showing Reasons for Visiting Public Health Care Facilities
Asthma

Chronic Diseases

Dental

General Check Up/Casualties

Immunization

I don't use these services

Pre/Post Natal

Other

Figure 5: Reason for visiting healthcare facilities

Number

of Problems faced by respondent at public health

Respondent
3

centres
I dont use these facilities

4
1
2
3
2
5
2
2
2

Long waiting period

Lack of information
Postponing of appointments
Staff absent
Impolite staff
Poor facilities
Recommended elsewhere
Incorrect diagnoses
I havent experienced much problem at public

health centres
Figure 6: Problems faced by respondents

13

Doughnut Graph Showing Employment

yes
44%

no
56%

Figure 7: Employment of Respondents

Bar Graph Showing Monthly Income

over 200,0000
100,000-200,000
50,000-100,000

1
2
3

30,000-50,000

15,000-30,000

Under 15,000

Figure 8: Monthly Income of Respondents

14

Bar Graph Showing Highest Level of Education of Respondents

Graduate

Undergraduate

Secondary

13

Primary

Figure 9: Highest level of Education of Respondents

Bar Graph Showing How Beneficial Are Services Provided

Extremely beneficial
Very beneficial

2
4

Beneficial

Somewhat beneficial
Not beneficial

6
4

Figure 10: How Beneficial Services Are Provided

Number
Respondents
6
4
3

of Ways to increase the quality of services

provided
Increase funding to public healthcare facilities
Increase the number of staff workers
Government needs to review the policy
improve it
15

and

3
3
1
2

Build bigger hospitals with better facilities

I dont think it can be improved
Make public clinic services 24-hour
Pay staff better; it will motivate them to improve

their performance
Improve public education

about

preventative

measures for diseases to limit the dependency on

1

public health facilities

Improve the archiving of patient records to reduce

waiting time.
Figure 11: Ways to increase quality of services

Pie Chart Showing Respondent's View on the Policy

12%
Good
Bad
Indifferent

28%
60%

Figure 12: Respondent view of the policy

Interview Result
Interview with Doctor Landel (MD) on call at the Spanish Town Hospital and
Clinic
Interviewer: On a daily basis what is the doctor to patient ratio and how has
16

the implementation of the no-user fee policy affected this?

Dr Landel: I am currently stationed in the casualties department; the
average day sees 6 doctors in rotation between day and night. On a daily
basis we receive about 230 patients, most of which are not serious but at
least 2-5 serious cases and possible admittances. Since the implementation
of the policy, I have seen increases in the amount of patients. I would say
about an 80 percent increase.
Interviewer: What types of cases are more common?
Dr Landel: Well, majority of the patients I look at obtain injury through
domestic violence and unfortunate accident (motor vehicles included).
Asthmatics and the elderly are also a large percentage of the cases I
receive.
Interviewer: How beneficial do you think the policy is?
Dr Landel: I think it has benefitted the majority of Jamaican people. It
definitely has benefitted the poor and the elderly. However, doctors and
nurses have seen a tremendous increase in the workload and barely any
increases in salary.
Interview: How do you think the policy can be improved?
Dr Landel: I believe that if more funding can be placed into healthcare to
improve facilities and equipment available then an increase in the healthcare
provided will be seen. Also, if we see an increase of specialised doctors
across

the

many

specifications

(urology,

cardiology,

paediatrics,

endocrinology etc.) the policy can be better complemented. Lastly, public

17

education of how to avoid certain illnesses and preventative measure would

have a spin off which sees less person running to the hospital for common
illness such as colds and fevers.

Analysis of Data

The questionnaire highlighted several trends. An overshadowing

majority of participants as seen in figure 3, 88 percent stated that they used
the services of the public healthcare. This implies that the bulk of the
population makes use of the no-user fee policy; that is approximately every 9
of 10 persons makes use of these amenities. Figure 3.1 shows that of the 88
percent, 72 percent state that this is their only affordable means of
healthcare. In addition 68 percent say they use the services sometimes or
often based on figure 4. In investigating the reason for using service we see

18

where immunization and general checks/casualties are the main driving

force; contrary to what previous research show. A combination of the two
encompassed 40 percent. Following those two asthma, dental checks and
natal care combined for 36 percent.
Figure 6 displayed the result of an open ended question. The
researcher was able to quantify the results using keys term and grouping the
general idea of what participants were implying. It revealed the most
prevalent shortcomings noticed were absenteeism of staff, poor facilities and
extensive waiting. These 3 combined for 48 percent. It also showed that only
8 percent have not experienced any problems. Figure 7 displayed the trends
in employment where a greater percentage (56) was employed. The majority
of the unemployed participants were over the age of 55 (Of the 44%
unemployed, 64% of that was the elderly). Figure 8 also delved into matters
of employment and personal economy. We see where 76 percent of
participants obtained less than $50,000 monthly with salary ranges of
$15,000 to $30,000 and $30,000 to $50,000 both contributing 28 percent.
This shows that the majority is low to medium wage earners. This result is
substantiated by figured 9 which show that 52 percent have received on a
secondary level education and another 16 percent receiving only primary
level of education.
60 percent stated that the services provided were beneficial to
extremely beneficial. This shows that a majority have benefitted reasonably
to tremendously from the no-user policy based on figure 10. Figure 11 was
19

also open ended and the aforementioned method was applied to quantify
information. Most persons stated that they believe that increase funding and
obtaining better facilities would improve the services. This majority are in
concordance with Dr Landel who provided the same ideas as to how services
can be improved. Majority of participants have a positive outlook on the
implementation of the policy with 60 percent reporting that it was a good
thing. 12 percent however, was indifferent to the policy. This 12 percent was
wholly comprised of the 12 percent that stated that they do not benefit from
the services.
One major fact which was highlighted by doctor Landel is the fact that
he said the number of patients he see on average has increase by 80
percent. This means that for every 5 patient that on average would see him
daily, 4 new patients are present now.

Discussion of Findings

The analysed findings displayed trends which support and counter

previous research sources. Through thorough analysis and comparison,

20

findings show that 88 percent of the population of the participant utilise the
services of the policy. Of this 88 percent 72 percent utilise this as their only
affordable means of healthcare. This supports the research presented by
Henry (2012) that states that 82 percent uses the services and 68 percent
have no other affordable means. This implies that the dependency of the
population on the policy is consistent and the policy has truly benefitted a
great deal of the population.
Of the entire population 68 percent says they utilise the services
sometimes or often. The main reasons being immunization followed by
general checks/casualties which amassed 40 percent. This is an anomaly as
it counters precedent findings which stated that the majority of cases come
from HIV/AIDS and natal care patients as presented by Willis (2013).
In relation to the question surrounding the major concern or
shortcoming of the policy was said to be the poor facilities; this stated by 20
percent. This support expectations and presented Fuchs (2000). This also
support the information presented CAPRI (2013). This shows that there is a
consistency in findings which indicate this to be of concern moving forward.
The implications worsening facilities may have on the healthcare can, at this
rate, lead to spiralling degradation of the sector; more so than present.
The finding show that 56 percent of the population is employed
however, a whopping 78 percent are low to medium income earners. This
implies that previous findings presented by Henry (2013) are accurate which
state that the poor benefits tremendously from the policy. This relates to the
21

aforementioned dependency on the policy as many persons cannot afford

alternative healthcare. The findings also show that the majority of the
population had not received more than a secondary education. Interpreting
these findings of employment, salary earned and educational it is possible to
deduce that the majority of the population which benefits from the policy is
found within lower to middle socio-economic classes. This also supports
findings previous noted by CAPRI (2013).
60 percent state the policy was beneficial to extremely beneficial to
them. Overall, 84 percent stated that the service has benefitted them in
some way. This corresponds with findings by CAPRI (2013). This show that
the policy benefits 4 of every 5 Jamaicans; this has been the major driving
force behind the longevity of the policy. This is further emphasised by the
interview completed, I think it has benefitted the majority of Jamaican
people. It definitely has benefitted the poor and the elderly, (Landel, 2014) in response to the question of how beneficial the policy was.
The majority expressed views that increased funding will increase the
quality of services provided by the policy. 24 percent stated that the policy
required greater funding and an additional 16 percent stated that the
improvement of staff would bring the services provided to an increased
efficiency. This is in agreement with surveys completed by CAPRI (2013) and
is supported by information presented by De La Haye (2011). With this in
mind one question what measure will be put in place to remedy the issue of
inadequate funding or rather, if anything can be done.
22

Surprisingly, only 60 percent expressed a positive view on the policy.

This is shy of in excess of 20 percent as expected due to previous findings
presented by CAPRI (2013). This anomaly may be as a result of assessment
overtime or just due to the focus population of the research. However,
results still indicate that the majority of the population have a positive
outlook on the policy.
Comparison this research to previous research, it can be highlighted
that major similarities are seen. These similarities, though some expressed
more than others, indicate consistency of information and may be indicate of
future occurrences. This research is beneficial as it provides members of a
future generation with statistic and diagrammatic representation of the issue
of free healthcare with the two aforementioned communities.
This research shows major similarities with previous research. This
implies that the shortcomings found are recurring issues that not only the
doctors who are greatly affected face but the entire population. This indicate
that though the policy is branded as beneficial, there are major inefficiency
which overtime, if not fixed, may derail the policy entirely. The study will be a
significant endeavour in the reviewing of the policy. The study will also be
beneficial to future research as it will not serves as bench mark statistics but
will relate information surround the concept of the no-user fee policy and the
issue and recommendations of people who provide the services and those
who use it. Moreover the research will provide educated recommendations
on how to evaluate and improve performances of policies implemented.
23

Conclusions

From the study conducted, the researcher sees where the no-user fee policy
has benefit the majority of the sample population. It was found that the
majority of the population has a positive outlook on the policy and the major
downfall of the policy is a lack of facilities or poor facilities due to a lack of
funding. Based on findings, it is safe to conclude that the member of the
communities of Lakes Pen and Lime Tree have benefitted significantly from
the policy however, the major issue faced is that of the conditions of
facilities.

Limitations

The respondent may not have truthfully completed questionnaires.

Some questions may have sensitive to individuals; question about
employment and monthly salary are sensitive and may not have
received factual responses.

Some respondents may have given socially desirable responses.

24

The questions were mostly closed ended and respondent may not have
been fully able to express their views.

In analysing and presenting open ended questions the responses were

categorised based on rubrics hence full responses were not presented
as it would have been tedious

The method of investigation was mainly quantitative to produce graphs

and charts etc., however, the may result in major qualitative data not
been received which may great implications on the research.

Recommendations

Based on finding several recommendations were made. Firstly, public

education about diseases and personal healthcare will not only limit the
strain on the policy but will also increase the overall health of the population.
Secondly, increase funding and greater monitoring of this funding will see
not only an increase in the quality of services and facilities but will limit the
mismanagement of resources due to corruption. In addition, a reviewing of
the policy to amend who benefits directly from the absence of user-fees will
lessen the strain on the economy. If members of the population who are
capable of paying user-fees are force to pay it will result in necessary
funding being present to not only increase the salaries of healthcare workers
such as doctor but will also provide funding for improving facilities hence
improving services.
25

Bibliography

CAPRI (2013) No User Fee Policy in Public Hospitals in Jamaica

Published: May 2013

Cunningham, A. (2013) Free Health Fallout - Too Much Freeness - No-UserFee Policy Worsening Poor Service
Jamaica Gleaner
Dated: June 11, 2013

De La Haye (2011) West Indian Medical Journal

The impact of a no-user-fee policy on the quality of patient care/service
delivery in Jamaica
http://caribbean.scielo.org/scielo.php?script=sci_arttext&pid=S004331442012000200013
Department
University

of
of

Community
the

Health

and
West

Psychiatry
Indies

Fuchs, V. (2007) Essays in the Economics of Health and Medical Care

NBER publishers
Chapter Title: The growing demand for medical care

26

Hibbert, K. (2015) Doctors want pressure applied to government to fix health

sector
Jamaica Observer
Dated: January 8, 2015
Retrieved
from:
http://www.jamaicaobserver.com/news/Doctors-wantpressure-applied-to-gov-t-to-fix-health-sector_18189598

Henry, B. (2012) Opposition says no-user fee saves patients $8b

Retrieved from: http://www.jamaicaobserver.com/news/Opposition-says-nouser-fee-policy-saved-patients--8b_12165921
Dated: August 08, 2012
Lagarde, M. Palmer, N. The impact of user fees on access to health services
in low- and middle-income countries. Cochrane (2011)
http://apps.who.int/rhl/reviews/CD009094.pdf

Willis, A. (2013) Free Healthcare A Blessing

Jamaica Observer
Dated: November 27, 2013

Appendices
Questionnaire

27

This survey seeks your opinion on the no user-fee policy which whether
directly or indirectly affects every citizen of Jamaica. The no-user fee policy is
the policy which allows person to utilize public healthcare services without a
cost being allotted to them (free healthcare). Indifference is define as a lack
of interest or concern; not caring.
Please answer all questions as appropriately as possible. If a question does
not apply to you, you may leave your answer blank or simple state that it
doesnt apply.
Please select by ticking the appropriate response
1. Age group:
13-25
26-40
41-55
Above 55
2. Sex:
Male
Female
3. Do you use public healthcare facilities (public hospital and clinic)?
Yes
No
3.1 Can you afford to utilize other means?
Yes
No
4. How often do you use public healthcare facilities?

Never

Rarely

Sometimes

Often

5. What is the main type of care you utilise from these facilities?
28

I do not utilise these services

Asthma
Chronic Disease
Dentals
General Check-ups/ Casualties
Immunization
Pre/Post Natal

Other, please specify _________________________________

6. What issues/problems did you experience at the public healthcare

facilities? (If you dont use public healthcare facilities just state that you
dont use the facilities)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

7. Are you currently employed? (Self-employed or otherwise)

Yes

No

8. How much money do you earn monthly?

under 15,00

15,000 - 30,000

30,000 - 50,000

50,000 - 100,000

100,000 200,000

over 200,000

9. What is your highest level of education?

29

Primary

Secondary

Undergraduate

Graduate

10. How beneficial are the services provided at these healthcare facilities?

Extremely

Very

Beneficial

Somewhat
Not

11. What measure can be implemented to improve the quality of services

provided?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
12 What is your view (outlook) on the implementation of the policy? (Do you
think it was a policy to implement?)
Yes, I think it was a good to implement
No, I dont think it was a good thing to implement
Indifferent

Maps

30

Figure i: road map of area

Figure ii: satellite image of area

31