the abolition of user fees in the jamaican public health system

299 Pages·2013·2.71 MB·English

by  Adella Campbell

THE ABOLITION OF USER FEES IN THE JAMAICAN PUBLIC HEALTH SYSTEM:
IMPACT ON ACCESS, CARE PROVIDED AND THE WORK OF THE
PROFESSIONAL NURSE

BY

ADELLA CAMPBELL

A thesis
submitted to the Victoria University of Wellington
in fulfilment of the requirements for the degree of
Doctor of Philosophy in Nursing

Victoria University of Wellington

2013
Abstract
The negative impact of user fees on the utilisation of the health services by the poor in
developing countries such as Uganda and Jamaica is well documented. Therefore, various
governments have been engaged in reforming public health systems to increase access by
underserved populations. One such reform is the introduction of free health services. In
Jamaica, user fees were abolished in the public health sector in 2007 for children under 18
years and in 2008 free health care was introduced for all users of the public health system.
This study evaluated the impact of the 2008 reform on the Jamaican public health system
at 1) the national level, 2) the provider level, and 3) the user level. Perspectives were
sought on access to care, the care provided, and the work of the professional nurse.
Participants were selected from the Ministry of Health (MOH), the four Regional Health
Authorities (RHAs), and urban and rural health facilities.
Data collection was done during March – August 2010, using a multi-layered
mixed methods evaluation approach, incorporating both qualitative and quantitative
methods. Methods included individual interviews with key policymakers (eight) at the
MOH and the four RHAs, as well as a senior medical officer of health (one) and
pharmacists (three); focus groups with representatives of the main practitioners in the
health system including nurses (six groups), pharmacists (one group) and doctors (two
groups); document reviews of the MOH and RHAs‘ annual reports, and a survey of
patients (200). Views on the impact of the abolition of user charges differed across the
three levels and among the health authorities, facilities, and perspectives (policymakers,
practitioners and users). Patient utilisation of the public health system increased
exponentially immediately following the abolition of user fees, then declined, but
remained above the pre-policy level. The work of health care providers, especially the
professional nurse, was affected in that they had to provide the expected and required
services to the patients despite an increase in workload and constraints such as inadequate
resources.
The research found that, while policymakers were optimistic about the policy,
providers had concerns but patients were satisfied with the increased access and the quality
care they were now receiving. Users also encountered challenges that constituted barriers
to access. In addition to providing further evidence about the abolition of user fees in the
public health system, this research provides important new insights into the impact of the
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nationwide abolition of user fees, as well as the impact of the policy change on the work of
the professional nurse. Equally, the findings highlighted the potential benefits, gaps, and
failures of the abolition of user fees‘ policy, and will serve as a catalyst to improve the
policy process regarding access to health services and the work of the professional nurse.
The findings of this research will be valuable in the planning of health-related programmes
for the consumers of health care in developing countries. Despite the need for further
research in this area, this research has contributed to the body of knowledge regarding user
fees and access to health care in developing countries.
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Acknowledgements
I must acknowledge divine guidance, without which this journey would have been
futile. Profound thanks to my supervisors Dr. Katherine Nelson and Associate Professor
Jackie Cumming for the tremendous support and guidance given to me. Their constructive
feedback and propensity for detail were catalysts to improve my work and ensured
completion of this study.
Thanks to the Commonwealth Scholarship Fund for giving me the opportunity to
study at Victoria University of Wellington, an opportunity that has empowered me to make
meaningful contributions to my country‘s development. Special thanks to the NZAid
Team that supported me throughout my journey here in New Zealand.
Special thanks to the faculty and staff at the Graduate School of Nursing,
Midwifery and Health, as well as Victoria University of Wellington for the support I
received and opportunities I was given during my time as student. I am also grateful to my
colleagues and Student Learning Support Services who took time out of their busy
schedule to proofread portions or all of my scripts. I must also acknowledge the valuable
contribution of the personnel from the Ministry of Health, Jamaica who provided well
needed data by email throughout the course of my study and I am eternally grateful to all
the participants without whose contribution this project would have been futile.
Finally, I would also like to acknowledge my family, students and friends who
were always there to assist and provide support at some stage of my work. Thanks
especially to my son Romaine who endured my absence from home for the entire period of
study.
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Table of Contents
Abstract ........................................................................................................................... ii
Acknowledgements ........................................................................................................ iv
Table of Contents ............................................................................................................ v
List of Tables ................................................................................................................ viii
List of Figures ................................................................................................................. x
List of Abbreviations ..................................................................................................... xi

Chapter 1: Introduction.................................................................................................. 1
1.1. Profile of Jamaica ................................................................................................... 2
1.2. Overview of health care in Jamaica ........................................................................ 6
1.3. Problem statement, aim and research questions..................................................... 10
1.4. Significance and relevance of the research ............................................................ 11
1.5. Thesis chapter outline ........................................................................................... 11

Chapter 2: The Jamaican health system ...................................................................... 14
2.1. Introduction .......................................................................................................... 14
2.2. Jamaica ................................................................................................................ 14
2.3. Development and reform of the Jamaican health system (17th – 21st Centuries)..... 15
2.4. Summary .............................................................................................................. 31
2.5. Financing the public health system (17th – 21st Centuries) ..................................... 32
2.6. Health service delivery and utilisation of the health care system ........................... 36
2.7. Patient‘s journey................................................................................................... 47
2.8. Conclusion ........................................................................................................... 50

Chapter 3: Literature review........................................................................................ 51
3.1. Introduction .......................................................................................................... 51
3.2. Search strategy ..................................................................................................... 51
3.3. Key limitations of literature review ...................................................................... 52
3.4. Impact of user fees ............................................................................................... 52
3.5. Jamaica and other Caribbean countries‘ experience with user fees ........................ 58
3.6. The impact of the abolition of user fees ................................................................ 59
3.7. Jamaican experience with the abolition of user fees .............................................. 67
3.8. The impact of the abolition of user fees on health workers .................................... 70
3.9. Impact of the abolition of user fees on the work of the professional nurse ............. 73
3.10. Conclusion ......................................................................................................... 74

Chapter 4: Theoretical framing.................................................................................... 76
4.1. Introduction .......................................................................................................... 76
4.2. Access defined ..................................................................................................... 76
4.3. Policymakers and access to health care ................................................................. 82
4.4. Providers and access ............................................................................................. 82
4.5. Consumers and access to health care .................................................................... 84
4.6. Nursing and access ............................................................................................... 89
4.7. Conclusion ........................................................................................................... 92

Chapter 5: Methodology and research design ............................................................. 93
5.1. Evaluation ............................................................................................................ 93
5.2. Mixed methods ..................................................................................................... 95
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5.3. Philosophical underpinning .................................................................................. 96
5.4. Design .................................................................................................................. 98
5.5. Data analysis ...................................................................................................... 104
5.6. Triangulation ...................................................................................................... 107
5.7. Ethical considerations ......................................................................................... 107
5.8. Rigour/validity ................................................................................................... 109
5.9. Conclusion ......................................................................................................... 110

Chapter 6: Results – National and user perspectives ................................................ 111
6.1. Introduction ........................................................................................................ 111
6.2. Policymakers ...................................................................................................... 111
6.3. Official statistics from Document Review .......................................................... 125
6.4. User results ........................................................................................................ 131
6.5. Conclusion ......................................................................................................... 151

Chapter 7: Impact of the abolition of user fees on the work of main health
practitioners and the professional nurse .................................................................... 152
7.1. Introduction ........................................................................................................ 152
7.2. Practitioners‘ and professional nurses‘ involvement in the policy process ........... 153
7.3. Changes in the work of the practitioners since the policy change ........................ 155
7.4. Practitioners‘ perspectives on funding and resources in the public health system 161
7.5. Quality and effectiveness of care ........................................................................ 166
7.6. Contribution to improving access to health services ............................................ 168
7.7. Practitioners‘ satisfaction with their work environment since the policy change.. 173
7.8. Practitioners‘ overall impression of the abolition of user fees policy ................... 178
7.9. Conclusion ......................................................................................................... 181

Chapter 8: Discussion ................................................................................................. 182
8.1. Introduction ........................................................................................................ 182
8.2. Overview of findings .......................................................................................... 182
8.3. Overall impression of the policy change ............................................................. 185
8.4. Impact of the abolition of user fees on access to health services .......................... 188
8.5. Impact on the work of main health practitioners and the professional nurse ........ 200
8.6. Conclusion ......................................................................................................... 215

Chapter 9: Conclusion ................................................................................................ 217
9.1. Introduction ........................................................................................................ 217
9.2. Strengths and limitations of the study ................................................................. 221
9.3. Lessons learned .................................................................................................. 223
9.4. Recommendations .............................................................................................. 227

Appendices .................................................................................................................. 230
Appendix 1. Ten leading causes of death among males and females in Jamaica: 2006-
2008 .......................................................................................................................... 230
Appendix 2. Policymakers‘ letter of invitation........................................................... 231
Appendix 3. Information sheet .................................................................................. 233
Appendix 4. Policymakers‘ and providers‘ consent form ........................................... 236
Appendix 5. Policymakers‘ interview schedule ......................................................... 237
Appendix 6. Checklist – document review................................................................. 238
Appendix 7. Providers‘ letter of invitation ................................................................. 239
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Appendix 8. Providers‘ interview schedule................................................................ 240
Appendix 9. Patients‘ consent form ........................................................................... 241
Appendix 10. Patients‘ questionnaire ........................................................................ 242
Appendix 11. Victoria University of Wellington ethical approval .............................. 250
Appendix 12. Ministry of Health, Jamaica ethical approval ....................................... 251
Appendix 13. Confidentiality agreement for nursing students .................................... 252
Appendix 14. Supplementary data for user survey .................................................... 253

References ................................................................................................................... 265

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List of Tables
Table 1. Social indicators of Jamaica 2006-2010…………………………………………..4

Table 2. Economic indicators of Jamaica 2006-2010………………………………………5

Table 3. Health financing indicators in the Jamaican public health sector 2006-2010…….7

Table 4. Ticket payment system for outpatients…………………………………………..32

Table 5. Network of service delivery facilities 2010……………………………………...38

Table 6. Classification of hospital………………………………………………………...38

Table 7. Total health centre and curative visits 2003-2007……………………………….46

Table 8. Attendance and source of referral to public Casualty Department 2003-2007…..46

Table 9. Health indicators 2003-2007 ……………………………………………………..47

Table 10. Summary of the actual design of the study……………………………………..99

Table 11. National and regional policymaker interviewees……………………………...112

Table 12. Utilisation patterns of the health system………………………………………126

Table 13. Types of cases seen at health facilities during 2009…………………………..128

Table 14. Modes of referral to Casualty in 2006 & 2009………………………………..129

Table 15. Health indicators for 2006 & 2009……………………………………………130

Table 16. Facilities used for patient survey……………………………………………...132

Table 17. Biographic data for respondents who completed the survey by RHA………...133

Table 18. Household composition and standard of living of respondents by RHA……..134

Table 19. Nationality, income and employment of respondents by RHA……………….136

Table 20. Current health status of respondents…………………………………………..137

Table 21. Diagnosed health conditions of respondents………………………………….138

Table 22. Respondents‘ utilisation of the health facilities by RHA……………………..139

Table 23. Respondents‘ perceptions of the service they received from the public health
system……………………………………………………………………………………142

Table 24. Respondents‘ knowledge of free services…………………………………….145
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Table 25. Respondents who received a prescription and use of alternative medicine…...147

Table 26. Respondents who were referred and hospitalised……………………………..148

Table 27. Respondents‘ perceptions regarding cost-related problems and access to health
insurance…………………………………………………………………………………150

Table 28. Practitioners focus groups and individual interviews…………………………153

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List of Figures
Figure 1. Map of Jamaica…………………………………………………………………...2

Figure 2. Hospitals and population by parish in the health regions……………………….27

Figure 3. Structure and function of the public health sector………………………………29

Figure 4. Structure of the Regional Health Authorities, Jamaica…………………………30

Figure 5. Typical structure of a hospital…………………………………………………..41

Figure 6. Typical structure of a health centre……………………………………………..42

Figure 7. Nursing structure………………………………………………………………..43

Figure 8. Patient‘s journey to accessing health care………………………………………48

Figure 9. The multi-layered approach to the research…………………………………….95

Figure 10. Diagrammatic representation of the mixed methods procedure used in the
study……………………………………………………………………………………….97

Figure 11. Age of respondents…………………………………………………………...133

Figure 12. Problems encountered by respondents while accessing care…………………146

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