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 Jamaica’s 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?
1

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.
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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 but a global village in which each country bears significant weight on
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 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
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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 equipment valued at over 2.7
million US dollars. These sources were useful in giving background information on the research
and also in the development of the research objectives.
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
4
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
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 nation’s
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.
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There remains an ongoing debate as to how the healthcare reform surrounding the nouser fee policy affects Jamaica and what effects, both positive and negative, does it have on the
economy. Several political 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.
6
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
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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 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.
8
Presentation of Data
Questionnaire Results:
Bar Graph Showing Age Group of Respodents
11
8
4
2
13-25
26-40
40-55
Figure 1: Age group of respondents
9
above 55
Pie Chart Showing Gender of Respondents
44%
Male
Female
56%
Figure 2: Gender of Respondents
Bar Graph Showings Respodents Who Use
Public Health Facilities
22
Respondents who use public
health facilities
3
Yes
No
Figure 3: Respondents who use public healthcare services
10
Bar Graph Showings Respodents Having No
Alternative
18
Respondents who have no
other alternative
4
Yes
No
Figure 3.1: Respondents who have no other alternative
Pie Chart Showing Frequency of Visits to
Public Health Facilities
12%
24%
Never
20%
Rarely
Sometimes
Often
44%
Figure 4: Frequency of visit to facilities
11
Bar Graph Showing Reasons for Visiting Public
Health Care Facilities
Asthma
3
Chronic Diseases
2
Dental
3
General Check Up/Casualties
4
Immunization
6
I don't use these services
3
Pre/Post Natal
3
Other
1
Figure 5: Reason for visiting healthcare facilities
Number of Respondent
Problems faced by respondent at public health centres
3
I don’t use these facilities
4
Long waiting period
1
Lack of information
2
Postponing of appointments
3
Staff absent
2
Impolite staff
5
Poor facilities
2
Recommended elsewhere
2
Incorrect diagnoses
2
I haven’t experienced much problem at public health centres
12
Figure 6: Problems faced by respondents
Doughnut Graph Showing Employment
44%
yes
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
7
15,000-30,000
7
Under 15,000
5
Figure 8: Monthly Income of Respondents
13
no
Bar Graph Showing Highest Level of
Education of Respondents
Graduate
2
Undergraduate
6
Secondary
13
Primary
4
Figure 9: Highest level of Education of Respondents
Bar Graph Showing How Beneficial Are Services
Provided
Extremely beneficial
Very beneficial
2
4
Beneficial
9
Somewhat beneficial
Not beneficial
6
4
Figure 10: How Beneficial Services Are Provided
Number of Respondents Ways to increase the quality of services provided
6
Increase funding to public healthcare facilities
4
Increase the number of staff workers
14
3
Government needs to review the policy and improve it
3
Build bigger hospitals with better facilities
3
I don’t think it can be improved
1
Make public clinic services 24-hour
2
Pay staff better; it will motivate them to improve their
performance
2
Improve public education about preventative measures for
diseases to limit the dependency on public health facilities
1
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
28%
60%
Figure 12: Respondent view of the policy
Interview Result
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Indifferent
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 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 education of how to
avoid certain illnesses and preventative measure would have a spin off which sees less person
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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 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
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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 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.
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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, 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
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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 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
20
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.
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
21
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.
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
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
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.

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
23
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.
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-User-Fee 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=S0043-31442012000200013
Department of Community Health and Psychiatry
University of the West Indies
Fuchs, V. (2007) Essays in the Economics of Health and Medical Care
NBER publishers
Chapter Title: The growing demand for medical care
Hibbert, K. (2015) Doctors want pressure applied to government to fix health sector
Jamaica Observer
Dated: January 8, 2015
24
Retrieved from: http://www.jamaicaobserver.com/news/Doctors-want-pressure-applied-togov-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-no-user-fee-policysaved-patients--8b_12165921
Dated: August 08, 2012
Lagarde, M. Palmer, N. The impact of user fees on access to health services in low- and middleincome 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
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 doesn’t apply.
Please select by ticking the appropriate response
1. Age group:
 13-25
 26-40
 41-55
 Above 55
2. Sex:
 Male
25
 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?







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 don’t use
public healthcare facilities just state that you don’t use the facilities)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
7. Are you currently employed? (Self-employed or otherwise)
26
 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?
 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?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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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 don’t think it was a good thing to implement
 Indifferent
Maps
Figure i: road map of area
28
Figure ii: satellite image of area
29