UNIVERSAL ACCESS TO UNIVERSAL COVERAGE THE PATH TO EQUITY, SOCIAL - - PDF document
UNIVERSAL ACCESS TO UNIVERSAL COVERAGE THE PATH TO EQUITY, SOCIAL JUSTICE AND PROSPERITY Dr. Kenneth Baugh, MP Opposition Spokesman on Health Sectoral Debate Presentation 2013/ 14 1 CONTENTS ACKNOWLEDGEM ENTS / INTRODUCTORY REM ARKS 1.0
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ACKNOWLEDGEM ENTS / INTRODUCTORY REM ARKS 1.0 CONSTITUENCY M ATTERS 2.0 THE HEALTH SECTOR – POLICY OF UNIVERSAL ACCESS 3.0 CURRENT STATUS AND THE CASE FOR UNIVERSAL COVERAGE 4.0 M EDICAL TOURISM & E-HEALTH / TELE-M EDICINE 5.0
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1.0 ACKNOWLEDGM ENTS / INTRODUCTORY REM ARKS
M r. Speaker, thank you for affording me this opportunity to speak in the Sectoral Debates 2013/ 14. Let me commend you on your stewardship as Speaker of the
an inspiration to us all. Let me pay tribute to the Leader of the Opposition, former Prime M inister,
adviseon, and speak to issues concerning the health and well-being of the Jamaican people. Like my colleagues on both sides of the House, I too feel and sense of awe and indebtedness to the people of our constituencies; mine being West Central St.
endorsement, as we convene to formulate policy, debate the budget, and pursue legislative work in the precincts of this historic, noble and hallowed chamber. We are humbled by the fact that some of our National Heroes and our great forebears sat on these seats and spoke within these very walls; shaping the future
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M r. Speaker, had I not taken the decision to venture into public life by way of representational politics, then I would, at this stage of my life, be feeling a sense
So, M r. Speaker, I am proud to be part of this exercise – the conduct of a Parliamentary Democracy, where the people are our sovereign – to whom we are answerable, and with whose consent we take part in this noble exercise. I have been lucky to have had a very understanding family, a family that has afforded me the time and the space to serve in this manner. I wish to thank my dear wife, my children and grandchildren for their support over the years and an apparent willingness to put up with my extendedbouts of absence from home as well as numerous family occasions. M y extended family, over these past sixteen years, has been the people of the Constituency of West Central St. Catherine. I pause to salute them at this time. I take this opportunity to thank all my workers who are supportive and dedicated to hard work, not only for the winning of elections, but for the implementation of initiatives and programmes aimed at improving their quality of life. I am deeply indebted to my Councillors, and Councillor care-taker, the Chairman and members of my M anagement Team, District Supervisors and all my agents, for
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their loyalty to the cause, and consistency over the years which have brought a level of stability and upliftment to the Constituency.
2.0 CONSTITUENCY M ATTERS
M r. Speaker, I have already recorded in this House my gratitude to former Transport & Works M inister, M r. M ike Henry and his team at the then Works Agency, who presided over the Jamaica Development Infrastructure Programme (JDIP). I am also deeply indebted to the Government of the Peoples’ Republic of China and to China Harbour Engineering Company (CHEC) for the effective work done in my Constituency. I also wish to thank the current M inister, the Hon. Omar Davies, for accommodating the continuation of very important work in the communities of Fairview and Ebony Vale. This work addresses almost half a century of frustration
repeated incidents of flooding and destruction of such infrastructure as: roads, drainage, homes and personalproperty.
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I will be even more grateful in the near future if the M inister were to accommodate us further in undertaking the plans that have been made for improved drainage,in addition to preserving the gains that have already been made. The most important achievement so far has been the provision of water supplies to Kitson Town, Buxton Town and their environs. The water system the communities now boast, alleviate more than half a century of extreme inconvenience, indignity and frustration. This has been largely due to the innovative leadership of the then Water & Housing M inister, Dr. Horace Chang. We have a commitment from the current M inister, the Hon. Robert Pickersgill to extend connections to neighbouring communities and to expand the catchment and pumping facilities of the Gold M ine system, which supplies the hills of St. Catherine centred around Brown’s Hall. Next year, I will be pleased to express thanks to him when this crucial project would have been completed. In general, there have been major improvements in the infrastructure of roads, water and community centres, and I must express my gratitude to the Urban Development Corporation (UDC), coming out of the Lift-up Jamaica programmes
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as well as the communities, where citizens contributed their labour and expertise in advancing the progress of these projects. Whereas major challenges still exist with regard to community roads, generally speaking, the state of the main roads has seen steady improvements over the past ten years. In the absence of timely maintenance, however, this investment and these important gains will be eroded. M r. Speaker, I am pleased to advise that the community of Kitson Town has embarked on an initiative coming from the people themselves, for the attainment
Community Centres, along with business &commerce; the revival of the market being at the centre of their efforts. Eco- and cultural tourism being undertaken by these people, bring to life the rich history and cultural vibrancy of this region, dating back to Juan de Bolas, Cudjoe, and the old parish of St. John where the original Parish Church is situated; replete with a range of artefacts and historical datathat have survived the passage of time.
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In addition to that M r. Speaker, the constituency boaststhe Belmont Property where our two most recent National Heroes, Alexander and Norman lived and worked before they embarked on their historic journey. M r. Speaker, the most important issue, about which I am passionate, is the failure
communities across the island. This is a fundamental issue as it goes to the heart
across the society, increasing urban-sprawl and inner-city formation, and the abuse and marginalization of our emergent young people; our boys in particular. In my view M r. Speaker, the restoration of the family and community requires a holistic, strategic and fully integrated approach, with the rural agricultural economy at the centre. These hills and valleys are fertile for a wide range of primary products. The farmers are traditionally skilled and knowledgeable about all the inputs. The interventions necessary for maximised production are: access to roads to arable land, activation of small water supplies, rain water harvesting, and most importantly, access to capital (finance and equipment). Of critical importance is a policy that is sensitive to and emphasizes, the quality of life and the livelihood of
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the Jamaican farmer, within the context of a stable domestic economy; an economy having strong links to agro-processing, tourism and export. At all costs this policy should aim to prevent the creation of a glut through importation, even in the current climate of increased global trade and liberalised trade agreements. M r. Speaker, this Honourable House will recall my questions regarding the importation of pork, which is not merely about pork, but more so, about a principle that has to be established. It has been reported recently that 3 M illion kilos of pork have been imported into the island. Pig farmers in my constituency have been unable to sell their pork and unable to feed their pigs. M r. Speaker, I believe in partnerships between large operators and exporters linking backwards, to small and micro-enterprises in a bid to upgrade quantity and quality of production in meeting international standards, bringing viability to the poor rural farmers, achieving food security and securing macro-economic
without such targeted and meaningful interventions.
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3.0 THE HEALTH SECTOR – THE POLICY OF UNIVERSAL ACCESS
M r. Speaker, I am surprised that at this time, the M inister of Healthsounded so sceptical and ambivalent regarding the question of user fees in public hospitals and health-centres. I have been very diligent, accommodating and responsible in this matter.I have made myself available for discussions to explain the position of the Parliamentary Opposition. M r. Speaker the Opposition is emphatically and irrevocably committed to the policy of Universal Access (i.e. without barriers) which is predicated on the abolition of user fees in hospitals and health-centres. We reject the idea that a means assessment test can determine who is capable of paying fees,based on a questionnaire utilized at the point of access to the service. M eans testing is simply not efficient and effective. They just don’t seem to work. Experience over the last 29 years has shown clearly that user fees that had been in place up to April of 2008,had an adverse impact on the health-seeking behaviour of the population. Of particular note, is its highly notorious effect on the poorer segments of society.
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M r. Speaker, in my discussions on this issue during the deliberations of the Standing Finance Committee in respect of the 2013/ 14 Estimates of Expenditure, I took the opportunity to inform the M inister and his team from the M inistry of Health, as well as colleagues in the House, of all the studies done and the literature available, locally as well as regionally and globally, to offer guidance on this issue. Let me at this juncture, remind this Honourable House that there is a resolution standing in my name, which, having fallen off the table, was replaced at the beginning of this legislative year,with the hope that discussions would take place, and the matter eventuallyreferred to a joint select committee of both Houses. As the M inister indicated in his presentation, I was his guestin the M inistry of Health, and had a great opportunity to explain in detail, the level of research that has been done on this matter. M r. Speaker, this issue was recently the subject of a lecture presented by Dr. Carissa Etienne, the newly appointed Director of the Pan American Health Organization (PAHO), which is the regional arm of the World Health Organization (WHO). This distinguished administrator, who hails from Dominica, happens to be a graduate of the University of the West Indies (the second such graduate to head
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PAHO, the first being Sir George Alleyne, now Chancellor of the UWI). She worked extensively with the WHO in Africa, Asia, Central and South America. She declared on her first visit to Jamaica that Universal Coverage for health care was the priority health issue for her term of office. She emphatically declared that user fees, which are “ out-of-pocket” payments at the point-of-service, based on a means assessment test to determine those with the ability to pay, was dangerousand should be abolished as it not only served as a barrier to health- care, especially for the poor, but in addition, often had the effect of causing financial devastation, driving the poor deeper into poverty. She gave statistics to show that hundreds of millions of people world-wide were being driven further into poverty because of the policy of user fees. She also informed the gathering that this issue was the subject of two resolutions debated, discussed and adopted at the World Health Assembly over two years, 2011 and 2012. This annual Assembly is a world gathering of Health M inisters and their teams including our own M inister.
years, finally abandoned user fees in 2008, and indicated that this situation should not be reversed.
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It is unfortunate that this lecture received no coverage in Jamaica, nor was it mentioned in the M inister’s presentation. It is as though it never happened,which is most regrettable, given the topical nature of this issue – an issue ranking as the most important perhaps for the M inistry of Health at this time. The truth is, M r. Speaker, Dr. Etienne was simply re-stating a long- standing,tested, tried and proven policy of the World Health Organization. I reiterate, that in the year 2000,Dr.Gro Harlem Brundtland, the then Director of the WHO , authorized a study by a top-rated committee of experts led by Dr. Jeffery Sachs, renowned Economist from Columbia University, who reported 12 years ago on the issue of macro-economics and Health. Part of that report addressed the issue of user fees for health services, and proceeded to advise middle-income countries like ours, to abandon user fees and instead, explore other available options, such as pre-payment schemes. Subsequently, the WHO put out a major World Health Report examining and rating health systems in different countries across the world. The current Director General of the WHO, Dr. M argaret Chan in her World Health Report of 2010, stated, and I quote, “ the obligation to pay directly for services at the moment of need,whether that payment be made as a formal or informal
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(under the table) basis prevents millions of people receiving health care when they need it. For those who do seek treatment, it can result in severe financial hardship, even impoverishment. The emphasis is moving towards Universal Coverage (pre-payment schemes) as a goal at the centre of debates about health services provision ..… … … .. especially in this time of economic downturn, rising costs, ageing population, increasing dependency ratios, increasing chronic non-communicable diseases and the high cost of high quality cutting-edge technologies which must be available to all.” And she continues: “ Abundant evidence shows raising funds through pre-payment (insurance schemes) is the most efficient and equitable base for increasing population
healthy subsidise the sick, the young subsidize the old; spreading costs over the life cycles of individuals.” Indeed, the larger the number of people participating in such schemes, the least costly and more efficient and effective it will be in providing coverage.
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The irony of all this, M r. Speaker, is that I was the M inister who introduced fees, albeit modest, for these services in 1984, thereby reversing the policies of the M anley-led administration of the 70’s, which said that there should be no fees nor private wards in public health-care institutions. There were waivers for beneficiaries of the Food Stamp Programme who earned less than $50 weekly, who were readily identifiable. Initially, the fees were at a level which did not impact significantly the health- seeking behaviour of people, neither the access of people to health-care. Over the next decade, it became obvious that the Government Health Services were becoming increasingly dependent on the collection of fees at the point-of-service in off-setting operating costs of hospitals and primary health-centres, and as the budget was reduced nominally and effectively by virtue of devaluation and inflation, and as such, the fees were increased to compensate for this loss of revenue, while the nominal provisions remained flat year over year. I cite an example M r. Speaker: the out-patient casualty user fee for patients in public institutions in 1993 rose from J$5 to J$20 (an increase of 300%); in the case
J$30 toJ$100 (an increase of 233%); and for private patients, the room and board
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charge (in public institutions) rose from J$50 TO J$500 (an increase of 900% in the year 1993). It became abundantly clear to all of us as politicians, that fees had become barriers to care, changing the health-seeking behaviour, especially of the poor, and forcing people to employ coping strategies, including postponing visits, applying home remedies; ultimately suffering more complications, more disabilities, and in the final analysis, requiring more costly and drastic interventions. The burden of fees, and financing the Health Sector was inequitably being borne by the poor – vulnerable persons: who had fewer or no other options, who were not covered by Health Insurance, who depended on the GOJ tax-funded hospitals as their safety net in times of illness. At this time they are also likely to suffer loss
suffer the effects of inflation on the cost of living. In many instances the cost of acute illnesses and the cost of catastrophic eventualities drive them deeper into poverty and all sorts of compromises. Any astute politician will recognize that in poor communities there is a disproportionately high incidence of strokes, heart attacks and diabetic
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complications in a relatively younger age group especially among women in their 40’s and 50’s, when compared to more affluent communities. M ultiple studies across the globe, attest to these trends. Indeed, it is well established that the poor suffer more complications arising from NCD’s as they are not able to sustain a consistent level of treatment in spite of the Jamaica Drug for the Elderly Programme (JADEP) and the National Health Fund (NHF). M r. Speaker, the Jamaican situation has been extensively studied and analysed. I want to draw your attention to this book titled “the Case for Selective User Fees in Health Care” - which anyone contemplating user fees and health insurance should study in detail. At this point I want to express my gratitude to Dr. Georgia Gordon-Strachan who sent me a copy of that most instructive text. She co-authored the book with five colleagues, professionals with expertise in the fields of Epidemiological Research, Environmental M anagement, Gender& Development, Health Economists in policy planning and development,and senior fellows and lecturers in the Sir Arthur Lewis Institute of Social and Economic Studies (SALISES),as well as the Department of Economics, both situated at the M ona Campus of the UWI.
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Theirextensive research culminated in a book,written in the hope that it would inform the actions of any administration wishing to re-impose user fees for health care in Jamaica after it was abolished in 2008. This book is an extensive prospective study, interviewing a large number of patients over three cycles of time, following them through their illness or pregnancy in the context of user
“ Despite the provisions to ensure that cost was not a barrier to heath care, there was evidence to the contrary, and that many of the complications seen were the result of inadequate access to affordable health care… … … … ..the evidence from the study seems to suggest that the cost of health care discourage utilization by a vulnerable segment of the population: clients with chronic conditions… … … … many
them extremely sensitive to increases in user fees, and their vulnerability was revealed in the cohort study where cost emerged as the major obstacle to care. The debilitating and disabling complications of these chronic conditions are not inevitable, but rather are avoidable, provided there is access… … … … . Faced with problems of financing their programmes, health regions have placed high priority
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aggressive discouragement of requests for waivers and therefore a denial of care for the needy.” Research evidence has shown that the world opinion is shifting away from user fees, accepting the overwhelming evidence that “ user fees as applied in several developing countries have not lived up to expectations and have had negative effects on the poor… … .have suppressed demand from the poor. After decades of experience of user fees, lobbyists have focussed their attention
withdraw financing if user fees in Health and Education were conditional for new loans. The World Bank was forced to make a drastic turnaround. In 2004, it acknowledged that in many instances fees had led to the exclusion of the poor … … … … … .. and(consequently) poverty reduction, equity and the millennium development goals will not be achieved if user fees are in place.” EXPLORING THE OPTIONS M r. Speaker, it is important to explain the options that are available. I believe that in general, the professionals who deliver health-care to our population are well-
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trained, and Jamaica, catalysed by the presence of so many tertiary institutions, led by the University of the West Indies, has achieved high standards in training and expertise. Had there been more resources, provided from the Consolidated Fund to the M inistry of Health, I believe it would have been effectively used to make the delivery of health-care more equitable and accessible. The global analysis of health systems worldwide has placed Jamaica at 53 out of 141 countries in its ranking in the year 2000, in terms of the quality of the services
respect of the per capita expenditure on health.
4.0 CURRENT STATUS AND THE CASE FOR UNIVERSAL COVERAGE
The M inister has said in his presentation that expenditure on Health is 4.7% of GDP which is pretty low, considering the fact that it stood at 11% in the ‘60’s , 8% in the ‘70’s, 7% in the ‘80’s , the lowest being 3.7% in 2000. M r. Speaker, the international benchmark is 10%, and that should be our aim here in Jamaica.
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When one uses constant values to compensate for inflation, it shows that the provisions for the M inistry of Health have remained flat over decades. The current devaluation against the background of the same nominal provision for the Health sector as last year, clearly means a significant fall in the purchasing value of the budget. Reports emanating from the regional and local management indicate that the authorities, in designing strategies to cope, are ending up in arrears to creditors and statutory bodies. In St. Ann the professionals have complained that deductions from their salaries for loan payments were not being passed on. It appears also that adjustments are being made in the emergency duty and on-call rota in order to reduce costs. Fears are also being expressed that interns who normally do a second year on the job as a Senior House Officer may not be
have to be repaid. One of the best innovations, however, is the requirement that patients had to “ pay to pee” , and to provide their own urine cup. It is clear that if we want to improve the services, we will have to generate more
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disastrous and retrograde at best. Against that backdrop, the only way to generate more income is through some form of National Health Insurance Facility, using pre-paid plans in which people can participate when they are well and earning, pooling their funds to cover risk whenever they get ill, especially in the twilight of their lives. Currently, somewhere between 12– 17% of Jamaicans are covered by similar schemes through private insurance. Of that amount, an estimated 34% are in the richest quintile. Only 8% in the poorest quintile have such coverage. The Jamaica Survey of Living Conditions 1998 – 2002 show that 11% of Jamaicans reported being sick while only 6.5% sought care, which means that 40% of those reporting ill did not seek care. Approximately 7% of Jamaicans were admitted to public hospitals and only 1% to private hospitals. The Government, owning 95% of such in-patient services is in a position to pursue a policy that will see it embarking on aNational Health Insurance Programme (NHIP), especially in light of the success of JADEP and NHF in providing significant relief to beneficiaries in the purchase of certain drugs. The matter has been studied in great detail in a 1984 document involving local experts, and which I have shared with the M inistry of Health and other interested
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90’s and a green paper was prepared. M r. Speaker, in addition to all of this the National Housing Trust (NHT) and the National Insurance Scheme (NIS) have a wealth of experience and can function as a useful conduit for the expansion of coverage. We should learn from Singapore which has combined pension, housing, education and health coverage into one Central Provident Fund (CPF). At the same time, participants as individuals are able to use their savings for pension investments. The Chilean scheme has been used as a model in many countries, involving a partnership between the public and private sectors and comprehensive coverage for rich and poor. They are renowned for their individualised, privatised pension scheme, which as a savings fund, has contributed to individualised investments competitively managed by 18 to 20 Trust Funds and has been credited with doubling the growth rate of Chile from 3.5 – 7% per year in the ‘90’s. It is clear that the issue is not just a matter of coverage for health-care but it provides financial protection against illness and against risk for everybody, and can guarantee access to cutting-edge technology for everyone, including the poor.
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Beyond that, M r. Speaker, it also guarantees Universal Coverage and access without barriers, making health-care affordableto all, and more readily available to all, resulting in revenue to the Health Sector which would be painless and far greater than that which would be derived from out-of-pocket payments. Finally, it would be a savings fund for the country that could contribute to investment, development and growth.
5.0 M EDICAL TOURISM AND E-HEALTH / TELE-M EDICINE
M r. Speaker, the University of the West Indies has graduated 4,000 doctors since its inception. This year,another 128 will graduate, while over 200 are scheduled to graduate next year, and 300 in the year following. In addition, the post-graduate training programmes in each discipline have been extremely successful. M ost notably, we have 55 in general surgery, 17 in ENT, 21 in Orthopaedics, 7 in Paediatric Surgery, 12 in Urology and 7 in Neurosurgery. These doctors have all been exposed in the course of their training, as part of their training regimen took them to specialist centres abroad.
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M inimalist surgery, meaning laparoscopic surgery is now well established across the length and breadth of Jamaica especially in certain centres, and together with the newest technologies in M RI and CT scans are effectively reducing in-patient
but with advancements in science is now less than a day in hospital. The fertility unit at UHWI is now housed in a new building named in honour of Professor Hugh Wynter, Professor of Obstetrics &Gynaecology, and will be
laparoscopic surgery to serve Gynaecologists, General Surgeons and Urologists. It is fully equipped to function using video technology and beamed at the same time to other major hospitals in Jamaica, namely, the Kingston Public Hospital (KPH), the M andeville Regional Hospital and the Cornwall Regional Hospital (CRH), as well as several centres in other Caribbean islands. Currently, they are able to conduct training sessions and consultations by video conferencing, and the facilities are designed with a modern new lecture room for training in these technologies. It is my information that they are intent on embarking on the newest frontier in surgical technology which is robotic surgery, where surgery on a patient is done
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from a remote centre, usually in the same operating theatre but from a different location using 3-D imaging with 10-fold magnification enabling very precise surgery especially in sparing nerves and preserving potency in total prostatectomies for cancer of the prostate. Again, this type of surgery reduces complications and duration of hospital stay. Importantly, M r. Speaker, this opens the door to Jamaica becoming a part of the new international frontier of globalised medicine and medical tourism. To participate in this requires that our medical facilities be upgraded to meet very specific standards in quality of care, using modern equipment backed up by the expertise we have among our professionals and the relationships that we have developed in the USA and Canada. Already, a Jamaican doctor seasoned in robotic surgery in the USA is planning to come the Jamaica to work with the local doctors in this new field of robotic surgery. Participation in this new dimension of medicine will contribute significantly to Jamaica’s GDP and employ the specialized skills we are generating in large numbers.
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M r. Speaker, training is now taking place in several government institutions, and the CRH is now training doctors in pre-clinical and clinical years as well as in post- graduate disciplines. To meet the standard to qualify for medical tourism requires the full support of Government, and plans that are to be laid to attract financing
I would recommend, M r.Speaker,that the Government uses the model established at the UHWI, of a semi-autonomousfacility with a private wing to serve not only visitors but the local population as well. I would advise against a free-standing hospital (stand-alone facility), dedicated to medical tourism. Tele-medicine would also result in reducing the burden placed on Accident and Emergency and Casualty Departments by equipping strategically selected health- centres with diagnostic facilities, enabling long distance consultations with medical teams. If we are to qualify for international recognition we have to satisfy the global community that our people are beneficiaries of Universal Access, Universal Coverage with equity and social justice. M r. Speaker, with this objective in mind, I commend the approaches I have
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Thanks again for the opportunity to participate in this Sectoral Debate M r. Speaker. M ay God bless us all, and may he continue to bless Jamaica – land we love.