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1983/84 to 1985/86, Although in Proportional and Real Terms Supply Allocations Were Reduced

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1983/84 to 1985/86, Although in Proportional and Real Terms Supply Allocations Were Reduced GOVERNMENT POUCY AND THE EFFECTIVENESS OF USER CHARGES IN JAMAICAN HOSPITALS Jamaica October 1988 Resources for Child Health Project John Snow, Inc. RI 1100 Wilson Boulevard, 9th Floor Arlington, VA 22209 USA Telex: 272896 JSIW UR Telephone: (703) 528.7474 Government Policy and the Effectiveness of User Charges in Jamaican Hospitals October 1988 Maureen Lewis, Ph.D. The Urban Institute THE RESOURCES FOR CPILD HEALTH PROJECT 1100 Wilson Blvd., Nilith Floor Arlington, Virginia 22209 USA AID Contract Number DPE-5927-C-00-5068-00 I. INTROUCTICK Jamaica has one of the healthiest populations in the developing world. Its infant mortality rate is 13 per 1000, life expectancy is 70 and the total fertility has declined sharply in recent years to 3 percent. The country's health problems are a combination of the heart disease, accidents and neoplasms found in developing countries, and of high maternal mortality (1.1 per 100 live births) and malnutrition that are associated with developing countries (Swezy et al., 1987). At the same time, Jamaica has been plagued by many of the economic and financial difficulties that are facing other developing countries. High debt, rising inflation, and restricted government budgets have also caused real reductions in the resources allocated to public health, including public health care services. The effects on health care have been sufficiently severe to prompt widespread concern both within the government and within the society at large due in large part to a perceived and actual decline in the quality of services (Ross Institute, 1985). In response to the crisis in public health care provision, the government has devised a range of means for dealing with the problem. The first of these was a revised user fee policy. A major innovation involved a revamping of federal collection and expenditure requirements to allow facilities to keep some portion of their revenues to both offer incentives to facilities to collect and to improve performance, and to supplement hospital budgets, which have sustained significant real budget cuts since the early 1980s. This radical departure from the British system of remitting all collected revenues to the central government involved Parliamentary approval and therefore broad, and high level support. ml.Jamaica:User roe Paper 2 This paper analyzes the user fee system and its effects on public hospitals. The nature and magnitude of Jamaica's macroeconomic and financial difficulties and the effects on the public health sector are provided as background to the analysis of the government's experience before and after the revision in user fee policy. As part of the analysis, the trends in hospital budgets, revenues, and expenditure of discretionary revenue are examined in depth, and the issue of equity is addressed. II. DATA Data on user fees were collected from Ministry of Health (MOH) files and those of each hospital region. Since the policy directive of late 1985 hospitals have made (quasi) monthly reports of earnings to the central Ministry and most facilities have submitted budgets proposals for spending the revenues. Fee earnings prior to 1985 were obtained from hospital records. Hospitals were contacted either in person or by telephone to obtain the data. A specific, written recuest was sent to each regional hospital (where all hospital financial data are collected and filed) through Ministry of Health channels; and, finally, follow up telephone calls and visits were made where necessary to ensure a complete inventory. Gaps in Ministry of Health reports after 1985 were supplemented by hospital records where possible. Nine facilities were visited and the director and administrator interviewed regarding the accuracy of the MOH data, the operation of the user fee system, the significance of the revenue to hospital operation, and the impact of the new revenue on hospital operation. All public hospitals are included in the study with the exception of Bellevue Psychiatric Hospital. m1.Jamaica:Usor roe Paper 3 III. STRUCTURE OF PUBLIC HEALTH CARE Jamaica's health care services are provided free or at nominal charge to all citizens, and no patient is denied care whether or not they can afford the assessed charges. Jamaica's public health care system includes 24 hospitals, 447 primary health care clinics, environmental health, and centralized services in the Ministry of Health to serve these networks (National Laboratory, blood bank, Island Medical Stores, and National Maintenance Unit). Hospitals are divided ,ato categories and regions. Categories are Type C (basic inpatient and outpatient care in medicine and maternal child health), Type B (includes specialist services in some areas), Type A (full range of secondary and tertiary care), and specialty and chronic care facilities. The full range of facilities and the level and kinds of services offered are summarized in Table 1. Regional hospital divisions allow the largest hospital to carry the financial management responsibility for the facilities in their catchment area. Budgets, user fee revenue management, access to centralized services and other functions are acconplished through the regional hospital, which can be Type A, B or C. Table 2 provides a list of the 23 public hospitals (excluding the quasi­ public University of the West Indies Hospital) with information on the level (Type), size, volume of inpatient, outpatient and casualty, and operating efficiency measures of occupancy and average length of stay (ALOS). Volume of patients varies widely with no apparent pattern among bed size, inpatients and outpatients. Occupancy rates are generally quite high, as would be expected in a largely free-care system. Spanish Town Hospital's 102 percent reflects the ml.Jamaica:User Fee Paper Table 1 Distribution, Number, Personnel, Catchment Area, and Service Provided at All Levels of the Public Health Care System Health Location/ Center/ Immediate Hospital Catchment Level Number Level of Personnel Area Services Provided Type I 245 Midwife, 2 CHAa 4,000-5,000 MCH home visits population Type II 93 Public health nurse, 10,000-12,000 Curative, pre­ public health population ventive and inspector; RN, MD promotive and dentist visit Type III 84b MD, nurse practitioner Parish center Curative and pre­ & dentist (who also ventive at more serve Type II centers) sophisticated level Type IV b Combination of Type Parish center Curative and pre­ III center and the ventive at more parish office sophisticated level Type V 25 MD, some specialists, Undefined Specialty out­ nursing care, dentist patient care & PHC Type C 11 Basic, district Parish center Hospital Inptient and out­ hospital with x-ray patient care in & lab. Surgeon for medicine & MCH emergency; 2-3 MDs Type B 4 MD specialists Urban centers Inpatient Hospitals and out­ patient, specialist service at least in surgery, inter­ nal medicine, OB/GYN & pediatrics Type A 5c MD specialists Kingston, Hospitals Full range of Montego Bay secondary and tertiary care Other 4d MD specialists Kingston Chronic Hospitals specialized care a. CHA - community health workers. b. Includes Type III and IV together. c. Includes University of the West Indies Hospital. d. Maternity, Children's, Psychiatric, and Chest hospitals. ml.Jamaica:User tl Table 2 Characteristics and Utilization of Public Hospitals, 19 87-88a Number Number of Type Outpatient Occ. of Beds Discharges Casualty Attendance Rate ALOS Kingston Public 514 12,715 73,823 84,655 Cornwall Regional 84 11.9 326 10,745 53,079 51,663 81 8.3 St. Ann's Bay 140 7,827 23,306 7,349 Sav-la-mar 95 4.8 194 6,821 20,281 13,082 Mandeville 77 6.6 163 7,629 32,957 24,171 Spanish Town 82 5.1 252 12,721 44,216 23,528 102 6.6 Princess Margaret 164 5,862 22,820 5,106 Port Antonio 72 4.4 125 3,724 11,518 6,357 Annotto Bay 66 6.7 122 2,930 8,454 407 57 7.7 Port Maria 94 2,541 8,343 Falmouth 5,696 58 6.7 102 2,555 5,127 2,566. Noel Holmes 56 8.2 55 2,286 5,508 189 D Black River 85 6.7 115 4,675 16,689 n.a.c Percy Junior 68 5.6 122 5,054 11,793 6,127 May Pen 83 4.7 70 3,177 15,909 1,529 Lionel Town 78 5.4 60 1,937 23,583 10,195 Linstead 66 7.1 50 2,427 10,792 1,869 63 4.8 Specialt, Victoria Jubilee (maternity) 229 15,732 0 51,169 71 National Chest 3.0 116 1,032 1,231 2,921 Bustamente (children's) 86 26.0 215 6,598 48,850 23,758 70 Bellevue (psychiatric) 6.7 1,600 525 0 4,988 Hope Institute n.a. n.a. (hospice) 52 188 N/A N/A Mona Rehabilitation 51 48.8 Ill n.a. N/A N/A n.a. n.a. Source: Hospital Statistics Reports, 1982-1988. n.a. = not available N/A = not applicable. a. Data are estimates b. Outpatient department but no clinic. c. Visits included in casualty. ml.Jamaica:User t2 4 extremely high occupancy rate in maternity where two women to a bed is common. Average lengths of stay are high overall, and generally exceed the 6.3 ALOS in U.S. short stay hospitals (NCHS, 1988). Victoria Jubilee Hospital's 3.0 day for maternity is quite low by international standards since high risk pregnancies are more likely to delivery at that hospital than at other facilities, and these women are more likely to need additional hospital days. IV. FINANCING PUBLIC HEALTH CARE: THE PROBLE I The comprehensive nature of subsidized care and the expansion of primary health care in recent years, combined with severe macroeconomic difficulties has taken a toll on the quality of health care.
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