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 classUser 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 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 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 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 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 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 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:

Figure 1: Age group of respondents

Figure 2: Gender of Respondents

Figure 3: Respondents who use public healthcare services

Figure 3.1: Respondents who have no other alternative

Figure 4: Frequency of visit to facilities

Figure 5: Reason for visiting healthcare facilities

Number of RespondentProblems faced by respondent at public health centres

3I dont use these facilities

4Long waiting period

1Lack of information

2Postponing of appointments

3Staff absent

2Impolite staff

5Poor facilities

2Recommended elsewhere

2Incorrect diagnoses

2I havent experienced much problem at public health centres

Figure 6: Problems faced by respondents

Figure 7: Employment of Respondents

Figure 8: Monthly Income of Respondents

Figure 9: Highest level of Education of Respondents

Figure 10: How Beneficial Services Are Provided Number of RespondentsWays to increase the quality of services provided

6Increase funding to public healthcare facilities

4Increase the number of staff workers

3Government needs to review the policy and improve it

3Build bigger hospitals with better facilities

3I dont think it can be improved

1Make public clinic services 24-hour

2Pay staff better; it will motivate them to improve their performance

2Improve public education about preventative measures for diseases to limit the dependency on public health facilities

1Improve the archiving of patient records to reduce waiting time.

Figure 11: Ways to increase quality of services

Figure 12: Respondent view of the policy

Interview ResultInterview 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 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 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. 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 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 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 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

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 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 JamaicaPublished: May 2013

Cunningham, A. (2013) Free Health Fallout - Too Much Freeness - No-User-Fee Policy Worsening Poor ServiceJamaica GleanerDated: 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 Jamaicahttp://caribbean.scielo.org/scielo.php?script=sci_arttext&pid=S0043-31442012000200013Department of Community Health and PsychiatryUniversity of the West Indies

Fuchs, V. (2007) Essays in the Economics of Health and Medical CareNBER publishersChapter Title: The growing demand for medical care

Hibbert, K. (2015) Doctors want pressure applied to government to fix health sectorJamaica ObserverDated: January 8, 2015Retrieved from: http://www.jamaicaobserver.com/news/Doctors-want-pressure-applied-to-gov-t-to-fix-health-sector_18189598

Henry, B. (2012) Opposition says no-user fee saves patients $8bRetrieved from: http://www.jamaicaobserver.com/news/Opposition-says-no-user-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 BlessingJamaica ObserverDated: November 27, 2013

AppendicesQuestionnaireThis 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 552. 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?

NeverRarelySometimesOften

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 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 200,0009. What is your highest level of education? Primary Secondary Undergraduate Graduate10. 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

Figure i: road map of area Figure ii: satellite image of area24