Report No. 1 3407-JM Jamaica Health Sector Review: Present Status and Future Options December 14, 1994 Human Resources Division Country Department III Latin America and the Cariblhe,in Region D. Documzent of the World Bank FISCAL YEAR April 1 - March 31 CURRENCY EQUIVALENTS Currency Unit - Jamaican Dollar (J$) Jamaica adopted a market determined exchange rate in September 1991. At the end of 1993, US$ - J$32.00 ABBREVIATIONS AND ACRONYMS AIDS Acquired immune deficiency syndrome CBR Crude birth rate CDR Crude death rate CHA Community health aides CIH Center for International Health DALY Disability adjusted life year ESSJ Economic and Social Survey of Jamaica GOJ Government of Jamaica GP General Practitioner HCL Health Corporation Limited HIV Human immunodeficiency virus HMO Health maintenance organization HRDP Human Resource Development Programme of the GOJ's PIOJ HSIP Health Sector Improvement Project (USAID) HSRP Health Services Rationalization Project (IDB) IDB Inter-American Development Bank IBMS Institution Based Monitoring System IMR Infant mortality rate JCTC Jamaican Commodity Trading Corporation LICA Life Insurance Companies Association MAJ Medical Association of Jamaica MCH Maternal and child health MMR Maternal mortality rate or ratio MOH Ministry of Health NGO Non-governmental organization NIS National Insurance Scheme NFPB National Family Planning Board PID Pelvic inflammatory disease PHC Primary health care PIOJ Planning Institute of Jamaica POS Point-of-service PPO Preferred provider organization PSOJ Private Sector Organization of Jamaica RGD Registrar General's Department of the MOH SLC Survey of Living Conditions STATIN Statistical Institute of Jamaica STD Sexually transmitted disease TFR Total Fertility Rate USAID United States Agency for International Development UWI University of the West Indies VEN Vital, Essential and Necessary (drugs) TABLE OF CONTENTS Country Data Sheet Preface Executive Summary PART 1: OPTIONS FOR REFORMING THE JAMAICAN HEALTH CARE SYSTEM.... I 1. INTRODUCTION AND OVERVIEW .................................................... I A. Macroeconomic policy framework .....................................................................1I B. The Jamaican health system ......................................................................1 C. The future ......................................................................6 2. STRATEGIC OPTIONS FOR THE JAMAICAN HEALTH SYSTEM ........................... 9 A. The rationales for government action in health .......................................................................9 B. Financing health care .......................................................................9 C. Provision of health care .................................................................... 11 D. Government's current policy package .................................................................... 13 E. Emerging issues .................................................................... 14 F. Rethinking government's role in the health sector .................................................................... 15 1. Selecting a basic package .................................................................... 16 2. Financing the basic package .................................................................... 17 3. Reducing the share of public financing for tertiary care . .................................................................... l9 4. Introducing measures to increase efficiency and contain costs .................................................................... 19 5. Redefining the Ministry of Health's role .................................................................... 24 G. Next steps .................................................................... 25 3. HEALTH STATUS AND DISEASE BURDEN .................................................... 27 A. Demographic trends .................................................................... 27 B. Burden of disease .................................................................... 31 C. Emerging patterns of morbidity and mortality .................................... 34 ]. Non-communicable diseases.34.................... ... 3 2. Injuries ......................................4........................................................................ 40 3. Infant and child health .......................4......................... ........... 41 4. Maternal conditions ...........................................................................................4..........................3............ .. 43 5 . C om m un icab le d iseases ............................. .................................................................................................... 43 D. Factors producing illness and health ............................ 45 E. Major Health Programs ............................ 46 4. ORGANIZATION AND UTILIZATION OF HEALTH SERVICES .............................. 51 A. The Public Sector ................................................................... 51 B. The Private Sector .................................................................. 59 C. Utilization of Health Care ................................................................... 61 D. Determinants of demand .................................................................. 67 E. Quality of health care .................................................................. 69 F. Equity .................................................................. 71 5. HEALTH CARE FINANCING ....................................................... 72 A. Overview ..................................................................... 72 B. Public sector health expenditures .................................................................. 74 C. Private expenditures ................................................................... 84 D. Insurance industry ................................................................... 88 TABLES Table 1.I Composition of Financing and Provision of Health Care, by Level and Sector ...........................4 Table 1.2 Composition of Health Financing, 1993/94 ..................................................................... 5 Table 2.1 Key Recommendations and Actions for the Short and Medium Term ...................................... 26 Table 3.1 Key Demographic Indicators, Jamaica and Selected Countries ................................................ 28 Table 3.2 Burden of Disease by Sex, Cause Type of Loss, 1990 .32 Table 3.3 Hypertension and Diabetes, Prevalence by quintile, residence, sex and age ............................. 35 Table 3.4 Malnutrition Rates for children under 5, 1978-1992 .............................................................. 39 Table 3.5 Malnutrition, by quintile, 1989-1991 .............................................................. 39 Table 3.6 Distribution of Injury, by cause, 1991 (percent) .............................................................. 40 Table 3.7 Hospital Inpatient Discharges, children aged 1-4, 1989-1990 .................................................... 42 Table 3.8 Immunization Coverage in Public Clinics, children under 1, 1987-1993 ................................. 43 Table 3.9 Incidence of Selected Infectious Diseases, 1989-1992 .............................................................. 44 Table 4.1 Public Health Care System, Hospitals And Health Centers, 1991 ............................................ 52 Table 4.2 Number Of Public Health Centers, By Type, 1981-1991 .......................................................... 53 Table 4.3 Bed and Average Occupancy Rates in Public Hospitals, 1988-1992 ........................................ 54 Table 4.4 Ministry of Health, Selected Established Posts and Staff In Post, 1993/4 ................................ 57 Table 4.5 Number of Physicians, by Specialty, 1993 ............................................................... 59 Table 4.6 Source of Curative Care by Patient Characteristics, SLC, 1991 ................................................ 63 Table 4.7 Source of Curative Care for Adults, by Income Level, SLC, 1989 ........................................... 63 Table 4.8 Health Care Contacts, Public Institutions, 1983-1993 .............................................................. 65 Table 4.9 Curative Visits toPublic Health Centers, by selected diagnosis, 1989-1992 ............................ 66 Table 4.10 Median Distances to Health Facilities ............................................................... 68 Table 4.11 Mean Expenditures for Health Care and Drugs, SLC, 1992 .................................................... 68 Table 4.12 Availability of Selected Drugs, by health center, 1990 ........................................................... 70 Table 5.1 Public and Private Provision and Financing of Medical Care, 1993/94 .................................... 73 Table 5.2 Total Health Expenditures and Financing, 1993/94 ............................................................... 74 Table 5.3 Composition of Recurrent Budget, by type of expenditure, 1991-1993 .................................... 82 Table 5.4 Proposal for Cross-Subsidization of User Charges ............................................................... 86 Table 5.5 Price Variations for a Sample of Drugs, 1994 ............................................................... 88 Table 5.6 Health Insurance Claims by Recipient ............................................................... 89 Table 5.7 Employees Enrolled in Private Group Health Insurance, 1980-1989 ........................................ 90 FIGURES Figure 3.1 Population Structures, 1990 and 2030 ............................................................... 30 Figure 3.2 Dependency Ratio, per 100 working population, 1990 - 2030 ................................................. 31 Figure 3.3 Disease Burden, by age group and sex, 1990 ............................................................... 33 Figure 3.4 Cancer in Men, 1958-1987 ............................................................... 36 Figure 3.5 Cancer in Women, 1958-1987 ............................................................... 37 Figure 3.6 Cervical Cancer in Women, 1958-1987 ............................................................... 37 Figure 3.7 Incidence of Reported Illness, by age and sex, 1989 .45 Figure 3.8 Incidence of Reported Illness, age 14 and older, by education, 1989 .46 Figure 4.1 Rate of Preventive Visit by age and sex, SLC, 1989 .62 Figure 4.2 Rate of Preventive Visit for adults, by income group, 1989 .64 Figure 5.1 GOJ Real Expenditures, Recurrent and Capital, 1982-1993 .74 Figure 5.2 GOJ Expenditures, with and without debt service, 1982-1993 ................................................ 75 Figure 5.3 Total MOH Expenditure as share of GOJ, 1982-1993 ............................................... 76 Figure 5.4 MOH Capital Expenditures as share of GOJ Capital, 1982-1993 ............................................ 76 Figure 5.5 Real MOH Expenditures, Capital and Recurrent, 1982-1993 ............................................... 77 Figure 5.6 Real MOH Capital Expenditures, by major program, 1982-1993 ............................................ 78 Figure 5.7 Reiative Share Of MOH Capital A and B Budgets, 1982-1993 ............................................... 79 Figure 5.8 MOH Capital A Expenditures, by major program, 1982-1993 ............................................... 79 Figure 5.9 MOH Capital B Expenditures, by major program, 1982-1993 ............................................... 80 Figure 5.10 Allocations Of MOH Recurrent Budget, by major program, 1982-1993 . .81 Figure 5.11 Real MOH Recurrent Expenditures, by major program, 1982-1994 . . 81 BOXES Box 2.1 Coordinated Care .12 Box 2.2 Decentralization Of The Jamaican Health System .14 Box 2.3 Divestment Of Hospital Support Services .21 ANNEXES Annex 1: References .94 Annex II Statistical Tables .98 Annex III: Calculating The Jamaican Disease Burden .106 JAMAICA: COUNTRY DATA SHEET Area: 10.99 (thous. sq. km.) Population (1993): 2.5 million Rate of Growth: 0.86 percent Population Characteristics (1990) Health (1993) Crude birth rate (per 1,000): 25 Population per physician: 2,117 Crude death rate (per 1,000): 5 Acute hospital beds per 1,000: 1.52 Total fertility rate: 3.0 Health expenditures per capita: US$105 Infant mortality rate (1991): 25.5 Health sector expenditures (% GDP): 8.9% Life expectancy at birth: 70 MOH expenditures (% of GDP): 2.7% Income Distribution Education (1991) % of National income - highest quintile: 49 Enrollment rate - lowest quintile: 5 Primary (net): 99 Secondary: 62 GNP per capita (US$, 1992)a: 1,340 World Bank Atlas methodolgy. PREFACE This report was prepared by Jill Armstrong, LA3HR (Economist). It is based on a vast array of existing reports and studies as well as data from The Survey of Living Conditions, an annual household survey conducted in Jamaica with World Bank support since 1988. The analysis of Jamaica's disease burden is based on information from the Registrar General's Department and the Health Information Unit of the Ministry of Health as calculated by the Harvard Center for Population and Development Studies. The report benefited from close collaboration with ongoing work supported by USAID's Health Sector Initiatives Project (notably a sub-contract with Latin American and Caribbean Health and Nutrition Sustainability Project) and IDB's Health Services Rationalization Project (notably the Center for International Health at Boston University). A green cover version of this report was discussed with Government of Jamaica officials October 5-6, 1994. Based on those discussions, minor changes were incorporated into this report. Valuable comments were also received from peer reviewers Maureen Lewis (LAI HR) and Dean Jamison (LATAD), as well as from Norman Hicks, LA3DR; Steven Webb, LA3C2, Margaret Grosh, PRDPH; Jacques van der Gaag, Julian Schweitzer, LA3HR; Juan Luis Londono, LATAD; and Philip Musgrove, PHN. Marie-Christine Theodore (LA3HR) assisted in the production of the document. EXECUTIVE SUMMARY i. Jamaica's health indicators are generally more favorable than those of other countries in the Latin American and Caribbean region at similar levels of income. Over the last 25 years there has been a progressive improvement in health status. Jamaica is well along in the epidemiological transition, reflecting both an aging population due to declining fertility and mortality, and changes in risks attributable to urbanization, industrialization and lifestyle. Non- communicable illnesses, such as heart disease and cancer, account for sixty percent of the total disease burden as measured by disability adjusted life years. Injuries (including traffic accidents and homicides) were responsible for almost one quarter. Communicable diseases made up the remaining sixteen percent. In this respect, Jamaica resembles more industrialized countries rather than its Latin American neighbors. Over the course of the next few decades--as the population ages--it can be expected that the prevalence of chronic illnesses will increase. ii. The Government is now at a critical juncture in health sector policy. The Jamaican public health system is presently overextended. Despite the major involvement of the private sector, the government still attempts to finance and provide the full range of health care services--inpatient and outpatient-- through a large system of public infrastructure without the means to support its effective functioning. Yet the large and growing share of chronic illnesses in Jamaica's disease profile, combined with public financing of most inpatient care, is a time bomb of costs that will eventually force the government to make choices about how much and what kind of care it can afford, and for whom. The Ministry of Health's response to inadequate health financing so far has been piecemeal--rationalizing some facilities, marginally increasing user fees, and firing temporary health workers. Instead of considering scaling back the range of health services provided by the public sector, government has maintained the appearance of offering a complete set of health interventions. This, despite the fact that care is rationed in the public sector through waiting lists and queues. iii. The choice for government is whether it should continue attempting to finance and provide the full range of health services--of questionable quality and access--or decide to prioritize and ration the services to be financed publicly and leave the remainder to private means. In some senses, Jamaica is fortunate in that the private sector has emerged as a major player both as a purchaser of health services and as a provider of care. The issue before government is how to rationalize the division of labor between the public and private health care sectors to improve health outcomes, and to increase equity, quality and consumer satisfaction in a more efficient manner. iv. Jamaica is not alone in grappling with this issue. Countries around the world--both developed and developing--are reforming their health care systems. The major issues facing policy makers involved in health sector reform revolve around the complex related questions of access to and quality of health services, who provides them and who pays for them. While the issues are similar, there is a wide diversity in the organization and financing strategies that have evolved. No one fits all countries. The Report draws on the experiences of other countries, notably the United States and in Europe, in presenting alternatives for financing and providing health care. v. A comprehensive set of recommendations is offered. Government should consider: (1) formulating a basic national package of the most cost-effective preventive and clinical interventions that would have the greatest impact in reducing Jamaica's current disease burden; (2) guaranteeing financial access to that basic package for all Jamaicans; (3) reducing the share of public financing for tertiary (and possibly specialty) care institutions; (4) introducing measures to improve incentives to make the health system--both public and private--more efficient and to contain costs; and, (5) redefining and reorienting the role of the central Ministry of Health towards one that is more regulatory and less managerial and controlling. vi. The Report is divided into two parts. The first part sets the overall macroeconomic context and government strategy, followed by a brief summary of the present status of the Jamaican health care system. It then lays out policy implications as well as options for reforming health care provision and financing. Broad recommendations are outlined. Part II provides a more detailed look at the Jamaican health sector, including the role of private providers and purchasers of health care. Part I: OPTIONS FOR REFORMING THE JAMAICAN HEALTH CARE SYSTEM 1. INTRODUCTION AND OVERVIEW A. Macroeconomic policy framework 1.1 Jamaica's present per capita income of US$1,340 puts it among the lower middle-income group of countries. A socially unacceptable portion of the population, however, lies below the poverty line-- about one third. After years of undertaking an adjustment process, Jamaica has now achieved a sound macroeconomic basis for restoring growth and reducing poverty. For the first time in nearly a decade, the country does not face a major financial crisis, macroeconomic imbalance or negative extemal shock. The most important goal for Jamaica is to accelerate economic growth from an annual rate of less than 2.5 percent experienced over the last four years. Raising growth to, say, 5 percent would move the country from poverty to sustained growth and lift it to the upper middle-income group in ten years' time.' 1.2 The Government's strategy for achieving this is to provide macroeconomic stability and appropriate incentives for private sector-led growth. Public sector modernization is a second key element of the overall strategy. Efforts to reform the public sector, such as divestment of selected state enterprises, will increase the availability of revenues for priority areas and improve the efficiency of the services it undertakes to deliver. Government's limited resources will need to be focused on activities that the private sector is unable or unwilling to provide and on areas where public resources will have the greatest effect. The key sectors for government involvement are infrastructure and human resource development (health and education). Public investment in the provision of adequate infrastructure is a vital ingredient to private sector growth. And, investing in human capital is essential for reducing poverty and enhancing growth. The associated increase in labor productivity from improving the human capital of the poor helps them to contribute more fullv to the growth process. Similarly, technological change--even in the private sector--can only be harnessed by a population that has mastered basic literacy and numeracy skills. In 1988, the Government established the Human Resource Development Programme (HRDP) which has sought to increase the share of public resources going to the social sectors and to improve the quality, efficiency and equity of social services. In addition, the HRDP helps to focus attention on the social sectors and to coordinate many of the public agencies and external financing agencies involved in human resource development. B. The Jamaican health system 1.3 Jamaica was a front runner in the adoption of an explicit public policy to promote primary health care (PHC). Performance in terms of health status improved. Life expectancy rose from 68 in 1970 to 70 in 1990; over the same period, the total fertility rate fell from 5.5 to 3.0. However, in terms of the cost of care, performance indicators are more worrying. In 1980, total health expenditures 2 consumed roughly 5 percent of GNP and of this, about 70 percent was funded publicly. By 1993/94, total health care spending had increased to 8.9 percent of GDP, of which the public share had fallen to I Jamaica, Medium Term Policy Framework, June 1994. 2 Cumper. 1986. approximately 35 percent.3 The increase in health care spending during the 1980s raises conce2s about cost escalation for health care--a topic that has been of growing concern in developed countries. In the United States, for example, cost escalation is one of the motivating factors behind health care reform. In 1980, Americans devoted 9 percent of GDP to health; by 1990 that figure had climbed to 14 percent--more than any other country in the world.4 Jamaica's share of GDP spent on health care is high compared to developed economies such as the United Kingdom (which spent 6.1 percent of GDP in 1990), Japan (6.5 percent). As a share of GDP, health spending in Jamaica is also higher than the average for the LAC region (6.3 percent), but it is within the range of 7-9 percent shared by Argentina (9.6 percent), Uruguay (8.3) and Chile (7.3).5 In addition, there are indications that access to public health care services--especially inpatient care--is less than equitable in Jamaica. Hence, while health outcomes are relatively favorable in Jamaica, the cost of attaining them has not been low. 1.4 In order to better understand Jamaica's health care system today, it is necessary to look back to the early 1970s. In the decade 1972-1982, there was rapid expansion of primary health infrastructure. The primnary care network, although in theory integrated, was created in parallel to the existing secondary and tertiary care system. Unfortunately, this expansion and two periods of severe cutbacks in real recurrent budgets (there was a one-third decline between 1982/3 and 1986/87; and again from 1990/91 to 1992/93) resulted in the neglect and subsequent deterioration of the hospital infrastructure. Moreover, underfinancing of recurrent costs for the expanded primary network, as well as for the provision of hospital services, began to take a serious toll on the quality of care--evident as early as the mid-1980s. Chronic shortages of health personnel in public facilities, lack of supplies (most notably drugs), and poorly maintained medical equipment began to result in long queues at public facilities. Frequently such waits met with little success in terms of coming into contact with health personnel or finding prescribed drugs at a public pharmacy outlet. 1.5 The Ministry of Health's response to the financing crisis in the mid-1980s was to find ways of saving costs and generating revenues in order to continue providing the full range of health care services. The actions taken in 1984-1986 included: increasing user fees in public hospitals (which had not been adjusted since their introduction in the early 1960s); laying off 600 community health workers who were an active part of the delivery strategy for PHC; and, converting some smaller district hospitals into rural polyclinics. Finally, in response to the deterioration in physical infrastructure and equipment, the Government solicited a US$92 million loan from the IDB to rehabilitate a handful of hospital facilities. It also sought support from the World Bank to refurbish primary care infrastructure. Although there was a small amount of new construction under these projects, they were in essence deferred maintenance transferred from the recurrent to the capital budget, eventually requiring repayment in foreign exchange. 1.6 These measures, however, were marginal and despite some real increases in the recurrent budget for health from 1987-1990, resources were still not sufficient to restore quality to the vast range of health services provided by the primary and hospital systems. Discontent with the poor quality of Center for International Health, 1994. 4White House, 1993. Govindaraj, R. et al., 1994 and World Development Report, 1993. 3 public facilities soon manifested itself in growing demand for private care. In response, the private sector began to provide increasing amounts of outpatient services. Jamaicans--including a substantial number in the poorest quintile--were willing or forced to trade higher prices for improved quality. Private sector outlets for drugs also mushroomed as public facilities experienced chronic drug shortages. 1.7 Not surprisingly, the volume of care delivered in public facilities dropped.6 Curative services at public health centers in 1993 were one third their 1984 level, while hospital outpatient visits fell off by nearly 40 percent. Excess capacity, beyond the handful of rationalized facilities, was evident. Between 1984 and 1993, 45 health centers were closed primarily due to lack of staff to run them; hospital wards have also been shut for similar reasons. 1.8 Table 1.1 provides a schematic outline of the present provision and financing of care in Jamaica. In terms of delivery of health care, Jamaica is a mixed system--the public sector is no longer the sole provider. The private sector is the leading provider of ambulatory care (preventive and curative services combined), accounting for an estimated 75 percent of all visits in 1993.7 The precise nature of outpatient services delivered through the private sector is not known with any certainty. However, it is likely that in addition to curative services, cl,ents also seek preventive care (such as maternal and child health and family planning) from private providers. Hospital inpatient care, on the other hand, is delivered primarily through public facilities, albeit with specialty services provided by consultant physicians to their private patients. This is due to the British tradition of granting "consultants" (i.e. doctors with private practice also employed in public hospital posts) admitting privileges and a portion of their public working week to care for their private paying patients. There are only a few private hospitals, with less than 5 percent of the island's bed capacity, for secondary care. There are no private tertiary hospitals in Jamaica. The nearest alternative for sophisticated levels of care offered by public tertiary hospitals is Miami. The private pharmaceutical sector has grown rapidly over the last decade in response to frequent shortages of drugs provided through the public sector. In terms of public health interventions, the public sector provides all environmental inspection services (i.e. inspection of food processing plants and restaurants). And, it delivers the bulk of health education messages for communicable diseases and maternal and child health promotion. For non- communicable diseases (such as diabetes, hypertension, cancers), the MOH to date has done very little nor committed much in the way of resources, despite the growing size of these problems. Non- governmental organizations (NGOs) have played a much more active role in health education and promotion and in providing early screening services for chronic conditions. 6MOH, Health Information Unit. Center for International Health, 1994. 4 Table 1.1 Composition of financing and provision of health care, by level and sector ACTIVITY/ PROVIDER 1 FINANCIER Comments LEVEL OF CARE_l _l _l Outpatient care _ Maternal/child health Public and private Public and private Unknown share of private, but likely to be substantial Family planning Public and private Public and private Curative care Private (approx. 75%) Private (approx. 81 %) Public (approx. 25 %) Public (approx. 19%) Inpatient care Public 95% of i.p. days Public 65% High share of private Private 5% Private 35 % financing due to private consultant fees for services delivered in public hospitals Secondary Public 95% Public 65% Private 5 % Private 35 % Tertiary Public 100%a Public 65 % There are no private Private 35% tertiary facilities Pharmaceuticals Public and private Private (approx. 82%) Relative size of Public (approx. 18%) providers unknown. Private/public price differentials as high as five. Public Health . _ ._. Environmental Public Public Possible cost l____________________ recovery options Health Education Communicable Public Public Fragmented delivery Non-communicable Largely NGOs, limited NGOs Underfunded in public public sector; potential for additional public funding of NGOs 1.9 According to best estimates, 65 percent of total health care expenditures in 1993 in Jamaica were from private sources. The bulk of private expenditures are for outpatient care. On the other hand, the major portion of what the government finances is hospital care--close to 70 percent of the MOH's recurrent budget. Over half of that is at tertiary levels. Around 38 percent of the total net recurrent budget is spent on the University Hospital, Kingston Public Hospital Complex and Cornwall Regional Hospital. Private outlays for inpatient care are also significant--estimated at 35 percent of total hospital expenditures. However, most of this is to pay for consultant doctors' fees (i.e. not hospital fees). 5 1.10 Total health sector expenditures were approximately J$9. 1 billion in 1993/94 or J$3,583 per capita (about US$105).8 Mirroring the rise in the expansion of private sector health care provision during the 1980s, there has been an increasing reliance on private out-of-pocket payments for doctor's fees and drugs and for private health insurance. By far, the largest source of financing were out-of- pocket expenditures which paid for just over half of all health outlays. Private insurance contributed 8 percent to total expenditures for health (Table 1.2). Table 1.2 Composition of health rmancing, 1993/94 (in millions current J$ and percent) Source of $J percent Financing l MOH 2,817.7 30.9 Other GOJ 326.4 3.6 Insurance 756.8 8.3 Out-of-pocket 4,916.8 53.9 NGOs 73.9 0.8 Overseas 221.0 2.4 TOTAL 9,112.6 100.0 Source: CIH, 1994. 1.11 Of public expenditures, secondary and tertiary care has consistently absorbed between 60 and 70 percent of MOH's total recurrent budget, while primary care has fluctuated below 20 percent. Public resources are thinly spread across the expansive public health care sector--chronic shortages of health personnel, drugs and maintenance persist. Public funds support hospital operating costs. In 1993/94, user fees contributed an average of 6 percent of public hospitals' current running cost., due to poor collection, low fees, and lack of sufficient differentiation between public and private patients.9 In the meantime, consultants in public hospitals are not required to pay for the use of public facilities and support services needed to care for their private in-patients. One estimate of the public subsidy in 1993 to private doctors operating out of public hospitals was J$87 million or 6 percent of the MOH's expenditures for hospitalization and 3 percent of the MOH's total.t0 Moreover, there is a general sense of abuse by these doctors about agreements of the amount of time, attention and priority devoted to their private patients to the detriment of public patients who are unable to afford private fees.'I In such an environment with general shortages of staff and supplies, this practice also raises serious equity questions. 8 op. cit. 9USAID, Health Sector Improvement Project. 0 Center for International Health, 1994. Adam, 1993. 6 1.12 Private expenditures for strictly medical care (i.e. excluding administration overheads, training, public health etc.) were about 68 percent of all such spending.t2 Of this, 70 percent went for ambulatory services, with approximately 15 percent each for fees related to inpatient care (predominantly doctors' fees but also hospital user fees charged to private patients), and for private purchases of drugs. 1.13 Although private insurance pays for only 6 percent of medical costs, approximately 15 percent of the total population has some form of private health insurance. Rapid growth of the private health insurance industry occurred in the mid-1980s. The impetus to seek insurance came from the working population, who were caught between declining quality of care in the public sector and rapidly rising costs for private care. Private care became increasingly costly for direct out of pocket payments and insurance coverage became included in contracts in negotiated with employers. Then as now, employers voluntarily contribute at least 50 percent of premiums and occasionally more.13 Because employers' contributions are tax deductible as a production expense, they not only are a government subsidy, but are also an attractive way of increasing salary packages outside limits of wage guidelines. The largest employer in Jamaica, the Government, also purchases private health care insurance for certain civil servants. There are five carriers of health insurance in Jamaica, four of which are life insurance companies. These companies offer a variety of indemnity packages, all of which have caps specified by item or annual maxima and/or coinsurance. Ceilings for selected types of services tend to be more generous in relation to charges for public services than private. There is only one health maintenance organization, based on a capitation scheme. 1.14 The demand for private health insurance arises primarily for access to private physicians and drugs, for routine, as opposed to risk sharing in the event of catastrophic, illness. In 1992, 30 percent of insurance claims were for doctors' fees, another 40 percent for drug purchases, and only 9 percent for hospital claims. 14 Use of private health insurance to finance public hospital services in Jamaica is not extensive because the government implicitly provides this coverage by highly subsidizing hospital costs. This is reflected by the low level of user fees and poor collection efforts. The government is subsidizing the insurance industry, as well as employers. C. The future 1.15 Jamaica's success in raising life expectancy and reducing childhood illnesses has resulted in a disease burden that is heavily slanted toward chronic, non-communicable diseases--sixty percent of the total loss of healthy life lost each year. Illnesses such as diabetes, hypertension and cancers are inherently more costly to treat if not detected early. And, because they most frequently afflict adults, as Jamaica's population ages--the proportion of the population over the age of 60 will double in 40 12 Center for International Health, 1994. 13 Kutzin, 1989. Life Insurance Companies Association of Jamaica, various reports. 7 years--preventing and treating chronic diseases will present a major challenge to the health care system. The remaining share of Jamaica's disease burden--communicable diseases such as sexually transmitted diseases and AIDS, and injuries due to homicides and motor vehicle accidents--are also more difficult to reduce solely through medical interventions. As is the case for many chronic illnesses, prevention-- although the best strategy--is difficult because it requires changing behavior. As Jamaica looks toward the twenty-first century, its health system--public and private--must not only continue to sustain primary health care services, but will also need to deal with the increasing demand for more costly chronic care. The major challenge facing government is how to most efficiently and equitably share the financing and provision of health care with the private sector. 9 2. STRATEGIC OPTIONS FOR THE JAMAICAN HEALTH SYSTEM A. The rationales for government action in health 2.1 There are three fundamental economic arguments why a government should intervene in the health sector. First, in the interest of poverty reduction, government should provide financial access to basic health care services for the poor. Second, there is a role for government in the health sector in promoting: public goods and those with significant externalities (e.g. treatment of tuberculosis or sexually transmitted diseases) which the private sector lacks the incentives to provide. Third, government intervention may be warranted to correct information-related market failures. Two often- cited examples are found in health insurance. Adverse selection occurs when insurers discriminate against bad health risks and cover relatively health people, while moral hazard arises when those who are insured take less responsibility for their health or are less restrained in using resources since the financial cost of illness to them is reduced. Other examples of information-related market failure include the asymmetry of information between the patient and the provider which may lead to excess use of services (and cost escalation), while imperfect competition among providers may generate excess profits and inefficient use of resources. 2.2 Government intervention in the health sector does not necessarily mean both financing and providing care. In fact, it is important to distinguish between the notions of who finances health care and who actually provides that service--the so-called "purchaser/provider split". There are many possible financing/delivery combinations involving both the public and private sectors. 2.3 Countries around the world--both developed and developing--are reforming their health care systems. The major issues facing policy makers involved in health sector reform revolve around the complex related questions of access to and quality of health services, who provides them and who pays for them. While the issues are similar, there is a wide diversity in the organization and financing strategies that have evolved. There is no perfect model, nor does one model fit all countries. The next section of this report draws on experience in the OECD countries and discusses two broad alternatives for financing health care. The chapter then turns to consider the Jamaican context and closes by outlining options and offering broad recommendations for how health care can be more efficiently and equitably financed and delivered in Jamaica. B. Financing health care 2.4 There are two broad alternatives for the role of the state in financing health care. The first is for the state to finance, or to mandate finance for, a reasonable basic level of health insurance for the entire population, which guarantees access within a budget constraint. Within the OECD, there are essentially two types of single-sourced financing of health care: tax-based financing, drawing on general revenues (e.g. U.K., Canada and Finland); and, mandated social insurance with fixed contributions from employers and employees (e.g. Germany and the Netherlands). The essential characteristic of this approach is that all health care funds pass through a single publicly-controlled or publicly- accountable spigot. This allows control of aggregate expenditure levels, more control over providers in terms of composition of services and their quality, while at the same time meeting the fundamental objective of guaranteeing universal access to all citizens. On average, 76 percent of health 10 care in OECD countries (excluding the United States) is publicly funded. This approach has also been widely adopted in Latin America, where 60 percent of health care is paid for by governments or government-mandated social security systems. Although these systems are largely single-sourced financed, they display a variety of provider reimbursement strategies (e.g. fee-for-service, capitation, salary). 2.5 Faced with cost escalation problems, nearly all OECD countries reduced the rate of growth of health spending in the 1980s through moderate or major health care reform. The reforms sought to improve efficiency, effectiveness and responsiveness to consumer demands for service delivery, without compromising their commitment to universal access to basic care.'5 Among examples of reforms pursued in those countries are: improved incentives and regulatory framework for providers and insurers (e.g. more autonomous and competitive hospitals and physicians, and contracting between public insurers and private providers); and, the introduction of competition into the production of health services within public systems (e.g. U.K.'s Trusts and GP budget holders). 2.6 The second model relies on a combination of private non-mandated insurance and out-of-pocket payments for financing the bulk of health care outlays; the state plays a relatively less significant role. Among developed countries, the United States is an example of this type of financing arrangement. The U.S. system of financing health care is characterized by a complex mix of public payers (federal, state and local governments), private insurance and individual payments. Many employers voluntarily provide health insurance coverage to their employees and dependents, while government programs cover the elderly and disabled (Medicare) and some of the poor (Medicaid). These forms of public and private insurance all differ in terms of benefits covered, sources of financing and methods of payment of care providers. However, approximately 15 percent of Americans (37 million) are not covered by any form of health insurance and therefore lack financial access to basic health care services provided largely by the private sector. 16During the 1980s, health care costs spiraled, fueled largely by third- party insurance systems that reimburse physicians on an open-ended fee-for-service basis (in which case neither the patient nor the provider has any incentive to control costs) and investments in expensive high-tech medical equipment. Administrative costs of the complex U.S. health insurance system also add to costs, absorbing 15 percent of health expenditures. Between 1980 and 1990, American health care spending increased from 9 percent of GDP to 14 percent. Without any reform, it is expected to reach 19 percent of GDP by 2000. Rising health care costs are already affecting the bottom line of many private sector companies. Between 1980 and 1989, employer sponsored health insurance plans increased as a share of payroll from 4.9 percent to 13.6 percent. And, the U.S.--like other developed countries--is faced by the daunting challenge of increasing chronic illness of a growing elderly population. Other characteristics of the U.S. system include poor geographic distribution of providers, underutilization of primary and preventive care and a high rate of inappropriate use of health services 15Saltman, (1992). 16 While some of the poorest are covered through the Medicaid Program, it tends to be the low income group, many of whom are employed, who lack routine access to basic medical care. Nevertheless those lacking insurance are not entirely without health care. Many of the uninsured receive services though public hospital emergency rooms or through private providers who finance the care through charity. 17 White House (1993). 11 (partially due to defensive medicine to avoid charges of medical malpractice). Despite these problems, there are advantages of the U.S. system. The vast majority of the population has access to state-of-the- art care, consumers are offered freedom of choice among a variety of highly skilled providers, and there is vigorous biomedical research and development. For those with health insurance, there are virtually no queues for any service, including elective surgery using the latest technology. 2.7 What are the outcomes of these two broad approaches? The contrast between the U.S. and the rest of the OECD is greatest not in health outcomes, but in expense. The U.S. spends more than any other country on health care. In fact, the present debate in the U.S. about health care reform is predicated on the fact that the present system is extremely expensive relative to health outcomes and inequitable in terms of access. And, despite having the highest health expenditures in the world, the U.S. ranked twentieth in infant mortality, seventeenth in life expectancy for males and sixteenth for females compared to other OECD countries.'8 In contrast, other OECD countries are able to provide a relatively comprehensive package of essential services for all their population at lower cost'9, higher levels of consumer satisfaction, and slightly better health outcomes. C. Provision of health care 2.8 Turning to the provision of health care--as distinct from financing it--neither theory nor practice provides a general rule for what the state should directly provide. There is a wide range of purchaser/provider combinations, including those that are predominately: (i) publicly financed but privately provided (e.g. Brazil and Canada); (ii) privately financed and provided (e.g. U.S. system); or, (iii) both publicly financed and provided (e.g Eastern Europe and before 1990, the U.K.). Although the extent to which governments are directly involved in the provision of care varies, a primary objective of public policy should be to encourage competition among providers--including those in the public sector. Government supply in a competitive environment can lead to increased efficiency and lower costs. 2.9 No matter who pays, the manner in which providers are paid has implications for cost escalation and efficiency. Third-party indemnity insurance creates the incentives for excessive and unnecessary treatment and, in general, leads to cost escalation. Co-payments and deductibles are an attempt to discourage unnecessary utilization of services on the part of the beneficiary. Various alternatives have emerged that have attempted to contain costs by managing utilization and provider payment levels (Box 2.1). These differ from more traditional fee-for-service third-party payer by integrating the financing and Greenberg (1992). It should be noted, however, that these figures may be slightly misleading because of the exacerbated social problems in the U.S. which result in significant health costs and adverse health outcomes. 19 In 1990, other OECD countries spent less: Canada 9.1 percent of GDP; Germany 8.0 percent; Japan 6.5 percent; Denmark 6.3 percent and the U.K. 6.1 percent. 12 Box 2.1 Coordinated care Coordinated care arrangements have become increasingly popular as a way to control costs in both the private and public sectors. The term "coordinated care" refers to a diverse and rapidly changing set of alternative health care delivery models that seek to integrate the financing and delivery of health services. The earliest model of coordinated care is the health maintenance organization (HMO). Several have been in existence for decades in the U.S., while the majority have been formed in recent years. Individuals who enroll in an HMO receive a comprehensive benefit package available only from a defined network of providers for a fixed payment (usually a monthly or yearly premium). To compensate for the restricted choice of providers, enrollees often face lower cost sharing and have little billing paperwork compared to fee-for-service medicine. HMOs themselves range from long established organizations that employ physicians, build their own hospitals and clinics, and only service HMO enrollees, to recent affiliations of solo practice physicians and hospitals who may also practice traditional fee-for-service medicine. Quality assurance at HMOs is an important issue. There is concern that HMOs, especially "for-profit" HMOs, have economic incentives to "underserve" their enrollees in order to live within the capitated payment. On the other hand, HMOs need to offer care of at least reasonable quality in order to be attractive to enrollees. A more recent model is the preferred provider organization (PPO) which selectively contracts with or arranges for a network of doctors, hospitals and others to provide services at a discounted price schedule based on anticipated volume. Individuals pay lower coinsurance rates if they visit physicians who have agreed to accept a lower price. Similar to HMOs, the PPO model includes utilization review and formal standards are used to select and maintain network providers and physicians. A recent development is the point-of-service (POS) network. POS networks start with an HMO and add a PPO component in an attempt to achieve both cost containment and freedom of choice of providers. Enrollees are encouraged to use HMO doctors by paying a higher coinsurance charge if they use doctors not affiliated with the HMO. By contrast, in a PPO, the doctor simply accepts a lower price for certain patients with no equivalent HMO structure with its emphasis on coordinated care. Studies suggest that HMOs can save about 20-30 percent compared with fee-for-service insurance, primarily by reducing inpatient hospital days. Coordinated care includes not only HMOs and PPOs but also a variety of other techniques to control costs by influencing patient care decisions before services are provided. These techniques include prior approval of hospital admissions, management of high cost patient care, controlling referrals to specialist through primary care physicians, selective contracting with hospitals and other providers, required second opinions for surgical procedures, profile analysis of provider utilization and practice patterns, and screening of claims prior to payment to avoid duplicate and inappropriate payments. Source: Adapted from George Greenberg, "A Layman's Guide to the U.S. Health Care System," Health Care Financing Review, Fall 1992, vol. 14. no. 1, pp.151-169 13 delivery of health services. Examples of these include paying a fixed amount per person (or capitation) as done in the British National Health Service or by health maintenance organizations (HMOs) in the U.S. This approach--also called "managed care"--encourages preventive and primary care in order to improve general health status and contain the cost of care mainly through reduced hospitalization rates. To be effective, however, there needs to be competition among providers to ensure that in order to keep costs down, quality of care is not compromised. Alternatively, a hospital or group of physicians can be provided with a fixed total budget to deliver an agreed set of basic services. Insurers (including the government) can jointly negotiate uniform fees for doctors (as in Japan or Canada). Or, insurers can set fixed payments for specified medical procedures, as seen in Brazil and in the U.S. Medicare program. D. Government's current policy package 2.10 Although the GOJ has adopted a wide range of policies in the health sector intended to increase efficiency, expand access to poorest groups and increase resources for the sector, an explicit goal of the MOH remains to "provide the Nation with effective preventive, educational and curative services for the promotion of health at all levels".20 To meet this goal, the GOJ attempts both to finance and provide the full range of health care services to all Jamaicans. Unfortunately, the result has been that resources are spread too thinly across all levels of care, making it difficult to sustain earlier achievements or to meet the emerging chronic health problems that characterize an aging population. Funds are insufficient to provide adequate combinations of vital inputs (i.e. pharmaceuticals and supplies, health manpower) and to maintain health infrastructure. The outcome has been the deterioration of quality of public health care services, the decline in and reduced access of their use and the emergence of the private sector in providing increasing amounts of health care, especially outpatient visits. 2.11 More recently, the government has acknowledged the need to foster private partnership in health care delivery, although the means to accomplish this have not been clearly articulated. Likewise, promoting health through personal responsibility (as opposed to treating sickness) has been recognized as vital to deal with the future onslaught of chronic health care problems21, but the financial resources presently committed to health promotion are not a testimony to this concern. Other policy steps, either under consideration or recently taken, are largely still within the rubric of government providing and financing the complete set of health interventions. Examples of such policies are plans to decentralize the health care system (Box 2.2), integrate the primary and hospital health care systems, and increase user fees. Little consideration has been given to the role that the private sector is already playing or could play, despite the fact that privatization or limited divestment of health care provision has been a frequent topic of proposals and studies for nearly a decade. To date, no action has been taken in even experimenting with alternatives. Some divestment of hospital support services is now being tried in selected hospitals. Difficulties in procuring health inputs (i.e. drugs and maintenance services) due to problems in attracting and retaining skilled personnel with civil service salaries, has resulted in the recent creation of a statutory agency, the Health Corporation Limited. 20 Budget speech by Minister of Health. Hon. Easton Douglas, 1991/1992 Fiscal Year. 21 Budget Speech by Minister of Health, Hon. Desmond Leakey, June 1994. 14 Box 2.2 Decentralization of the Jamaican health system Two central units manage the public health system in Jamaica: one is responsible for the delivery of primary care, and the second for secondary and tertiary care services. Both units report to the Principal Medical Officers at the Ministry's Headquarters. Except for direct medical referral from the primary care system to the hospitals, these two vertical units are not integrated, as is illustrated by the differences in the geographic organization of their management systems. The primary care system is divided into four regions, within which parish and district level authorities oversee health care delivery. In contrast, responsibility for supervising the island's 23 public hospitals lies directly with the MOH's central headquarters. Nine regional Boards provide varying levels of input into hospital activities. However, these Boards do not play an active role in supervision, and have little authority for decision- making. As a result of the centralized management structure of the hospitals, the MOH headquarter office has been responsible for resolving crises at facilities in each of the island's 14 parishes. From this distance, Ministry staff have been unable to sustain effective, responsive management. Yet the management staff at the hospitals--a triumvirate which includes a Senior Medical Officer, a Nurse Matron and an Administrator--have not been authorized to manage basic functions such as reviewing, hiring and firing staff. In fact, final authority rests with the Ministry of Public Service (MPS); routing of personnel actions through MPS leads to delays and restrictive salary and benefits policies undermine efforts to develop incentive schemes critical for improving staff performance. Hospital administrators are also restricted in purchasing pharmaceuticals and supplies from alternative sources when the central procurement system fails. More than five years ago, recognizing the shortcomings of this system and exhausted by the strain of attempting to manage problem-ridden facilities in the far reaches of the island, the MOH stated that it planned to decentralize oversight of the health services delivery system. Since then, a number of alternatives have been considered, but no policy decisions have been taken. And despite substantial technical assistance, no detailed implementation plans have been developed. In the meantime, however, the strengthening hospital management systems and drawing up plans for improving the referral system has been undertaken through ongoing foreign assisted projects. Under the USAID- funded Health Sector Improvement Project, chief executive officers were recruited, installed and trained at 7 of the islands largest hospitals in 1993. Unfortunately, since the decentralization program has not been implemented, the MOH has not yet defined the responsibilities or levels of authority that will be delegated to local managers. Source: Health Sector Improvement Project and the Latin American Health and Nutrition Sustainability Project. E. Emerging issues 2.12 What are the emerging issues in the Jamaican health sector? Jamaica can be characterized as having first world health problems, facing first world prices for many health inputs (such as manpower, drugs and equipment) and having a third world purse. The first issue is that the public sector presently lacks the financial and managerial resources to provide all potentially useful health services to all 15 Jamaicans. Public budgets have been, and will continue to be, limited. Given that, a major policy question facing Jamaica is whether or not to limit the number of health interventions that are financed publicly--and for whom. 2.13 The second key issue is cost escalation in both the public and private delivery systems, and its implications for technical efficiency. Despite the large role mandated for the public sector, Jamaica today resembles more the U.S. system than the approaches followed elsewhere in the OECD in terms of the private sector financing the bulk of health care expenditures.22 Given the present organization of the Jamaican health care system, the potential is for great cost escalation. Why? First, over time the share of inherently more costly chronic illnesses will grow as the population ages. The impact of this on costs will be particularly felt by the public sector because it not only provides, but finances, much of the inpatient care especially at the most expensive tertiary levels. Second, the geographic proximity to the U.S. and Canada places pressures on input prices, especially on mobile health manpower. Jamaica also faces international prices for imported drugs and medical equipment. The closeness to North America is also likely to influence demand for more sophisticated health care using the latest technology. Third, the private sector is largely unregulated and paid almost exclusively on a fee-for- service basis (a substantial portion is paid for by third-party indemnity insurance plans). Moreover, there is little competition from the public sector; patients are willing to pay for private care even when public services are nominally free. 2.14 The first two issues point to a third area of concern: equity. Thinly spread public expenditure has sent those who can afford to pay to the private sector for outpatient services. Poorer quality of care in public health centers is "reserved" for those unable to pay private fees. Inpatient care is usually available first for those who can pay private physicians' fees. Cost escalation will only distribute limited government resources more sparsely, with further implications for quality of care for those unable to afford private services. At the same time, cost escalation in the private sector will make it even more beyond the means of poorer groups who would prefer not to face long queues in public hospitals or clinics void of staff and drugs. F. Rethinking government's role in the health sector 2.15 The picture of health care delivery in Jamaica has changed dramatically over the last 10-15 years with the emergence of the private sector as a major provider and financier of health care. Looking ahead 10-15 years, this system must also deal with an inevitable increase in the demand for chronic health care services that are inherently more expensive to treat. The government is now at a critical juncture in health sector policy and must face the difficult question of what health care services it will finance, and for whom, and what it will actually provide. This question is also part of a larger set of issues which Jamaican policy makers are contemplating; namely: what is the appropriate role for government in the delivery of services. In the case of health, it also must also deal explicitly with the issue of what the role of the central Ministry of Health should be. 2.16 One option would be continue along the present path of financing and providing health care. Private finance would continue to cover most expenditures, especially out-patient services. Public 22 For example, 58 percent of all health care expenditures in the U.S. in 1990 were private; of this 33 percent was private insurance and 20 percent out-of-pocket. (Greenberg, 1992). 16 finance would concentrate on hospital services, especially tertiary care, for whoever can gain access. They would also continue to subsidize those consultants who provide specialist services in public hospitals. Continuing along this present course will also eventually mean that government will be left with the full financial responsibility of providing higher-cost, lower cost-effective services to meet the growing demand for chronic care. Moreover, if user fees were raised in public hospitals and collection efforts improved, the likely result would be an expansion of fee-for-service private health care insurance which would only further escalate costs. Finally, because much inpatient care is presently rationed by ability to pay, this approach will also worsen the inequitable access to hospital services and the quality of primary care delivered through the public sector. 2.17 Based on the present composition of the Jamaican health sector, this report offers an set of policy recommendations which together represent a comprehensive package that seek to address the issues highlighted above. It should be noted that within these recommendations are a series of options that must be developed more fully in the Jamaican context, as will appropriate sequencing. As a starting point, it is important for the government to acknowledge, and take advantage of, the magnitude of the private sector in both providing and financing health care and, in that light, reconsider the size and focus of the public health sector. The set of recommendations is outlined below, followed by a detailed discussion of each point. Government should consider: (1) formulating a basic national package of the most cost-effective preventive and clinical interventions that would have the greatest impact in reducing Jamaica's current disease burden; (2) guaranteeing financial access to that basic package for all Jamaicans; (3) reducing the share of public financing for tertiary (and possibly specialty) care institutions; (4) introducing measures to improve incentives to make the health system--both public and private--more efficient and to contain costs; and, (5) redefining and reorienting the role of the central Ministry of Health towards one that is more regulatory and less managerial and controlling. 1. Selecting a basic package 2.18 Priority in selecting the interventions to be included in a basic package should go to those health problems that cause a large disease burden and for which cost-effective interventions are available. For example, a large portion of the health problems among children under 5 in Jamaica (see Table 3.3) can be addressed by relatively cost-effective interventions. The exception is congenital problems which account for about 10 percent of the disease burden in this age group, but for which no cost-effective interventions are known. For adults, the sub-set of health problems which account for a significant share of the disease burden and which have cost-effective interventions is much smaller. This reflects the main challenge facing the Jamaican health system: as the population ages, the marginal 23 World Banki, World Development Report 1993, pp. 63-65. 17 cost of a year of healthy life gained rises sharply. For example, cerebrovascular disease is the top cause of healthy life years lost, but interventions to address it are less cost-effective. In general, many cost effective interventions are preventive or primary in nature, such as those to reduce or treat many sexually transmitted diseases. However, not all preventive measures are cost effective. By the same token, there are some cost-effective measures for selected curative interventions (such as surgical procedures for cervical and breast cancer). On the other hand, other medical interventions may be less cost-effective (such as treatment of highly fatal cancers of the lung, liver and stomach or intensive care 24 for severely premature babies). 2.19 In addition to clinical interventions that should be considered for the basic package, there are a variety of cost-effective public health interventions that are presently underfinanced in Jamaica. Some of these fall under the category of public goods for which government will need to devote increased public resources. One area of inadequate financing is health education and promotion of healthy lifestyles aimed at reducing and/or delaying the onset of chronic illnesses. Primary prevention to reduce accidents (i.e. motor vehicle accidents, falls and burns) and homicides will require a broader multisectoral approach, such as those already initiated by government for road safety. And while the family planning program has been successful, it is financed with support from a bilateral donor which has already signaled its intention of phasing out support for the supply of contraceptives. Careful consideration in terms of the level of government financing required to sustain already wide acceptance of contraception is warranted, particularly measures to cover hard-to-reach groups (such as adolescents and the poor). 2.20 The disease burden analysis described in Part II of this Report highlights where Jamaica's health problems lie based on cause of death data. Refinements to this analysis should be undertaken, especially to validate estimates of the burden caused by disability (e.g. mentally related illnesses, substance abuse and traffic accidents). In addition, detailed Jamaica-specific cost data on interventions to treat or prevent major illnesses are needed to determine relative cost-effectiveness before considering the contents of a basic package. Where to draw the line in terms of what to include will depend on the public financial resources available for health care and on the size of the population requiring government support (i.e. the poor).25 2. Financing the basic package 2.21 Government should take steps to ensure that all Jamaicans have financial access to services contained in the basic package (items that are not included could still be financed through private means). Here, there are a variety of financing options, although each has different implications for the size of the package, for meeting poverty reduction and equity objectives, and for cost containment. 2.22 One option would be for government to finance the entire package that would cover basic health care expenses for all Jamaicans. This could be achieved through continued use of general tax 24 Op cit. 25 The state of Oregon conducted such an exercise where interventions were ranked according to clinicla effectiveness--not cost--by Oregonians from those with the most to least positive expected treatment outcomes. The state budget then determined how far down the list services could be financed each year. 18 revenues (i.e. along the lines of the UK's National Health Service). The cost of the package would be determined by the contents of the package and the population to be covered. Obviously, an iterative exercise to select the package will undoubtedly be conducted based on the resource levels available. Although tax rates are currently high in Jamaica, there may be increased revenues through enhanced tax collection efforts recently introduced by the government. Alternatively, given the government's divestment of some productive activities to the private sector, there may be additional resources available for government financing of social services--a stated priority area. Nevertheless, the government budget is limited and even with some increase to the health sector, this option would effectively reduce the set of the interventions presently financed by the public system. This is because it would involve switching back to public financing many of the outpatient services currently sought by many Jamaicans who can afford to pay for them. Depending on the regressivity of the tax system, such universal public financing could lead to subsidies for wealthier Jamaicans. Equity concerns would, however, be addressed under this option by ensuring financial access to the poor for a basic set of services. 2.23 Another option would be for the private sector to continue financing most expenditures, but with public resources concentrated on financing the basic package for a sizable portion of the population who cannot afford private providers--the poor. In its purest form, this expenditure switching would entail increased levels of cost recovery (approaching full cost) in public facilities for those able to pay combined with rigorous collection efforts. Reducing the substantial public subsidy currently accruing to private physicians operating in public hospitals should also be introduced. For the poor, vouchers for health care, similar to Food Stamps, could be issued entitling them to services specified in the basic package. 2.24 A third option would be for government to mandate through legislation that all Jamaicans be insured for the minimum set of services included in the basic package. Persons could be insured under an employer-provided plan or be self-insured. The form that the insurance sector would take on would also need to be considered. Here, options range from establishing a National Health Insurance Fund (where employers/employees or individuals pay into a single publicly-controlled and administered ftund) or some combination with private insurance. Over the past five years, there have been several proposals for a national health insurance scheme. One, developed in 1992, was based on a managed 26 care service with a network of preferred providers. Currently, there is work underway to develop a pre-paid plan where low- to middle-income consumers would be entitled to a range of services at government hospitals and primary care facilities. A pilot scheme at Mandeville and May Pen Hospitals is being proposed. Finally, a parliamentary sub-committee is also exploring this issue. 2.25 A financing instrument for those unable to afford insurance would also need to be defined under this option. One possibility is an adaptation of the Food Stamp Program with the issuance of vouchers for the basic package funded through general tax revenues.2 One concern under this option would be the size of public sector resources needed to cover adequately the substantial numbers of people who fall below the poverty line--an estimated one third of the Jamaican population. Trevor Hamilton and Associates (1992). Final Report: Pilot Study on National Health Insurance and Managed Care. 27 Thailand, for example, has a Health Card system which was used to reach large rural and self-employed populations with varying levels of copayment for the Card, depending on ability to pay. 19 3. Reducing the share of public financing for tertiary care 2.26 The design of the basic package and the decision about what government will finance leads to the third recommendation: government should redirect public financing away from the handful of tertiary institutions--which presently consume 38 percent of the MOH's recurrent budget--toward more cost-effective interventions at primary and secondary levels. According to the 1993 World Development Report, very few cost effective interventions require sophisticated hospitals or specialized physicians. Most can be delivered by effectively functioning health centers and district hospitals offering basic surgery and emergency services. Limited public investment in tertiary facilities is warranted to support research and training, but below current levels. Training should also be more directed toward delivering more cost-effective interventions, which should include exposure at district hospitals and health centers. In the medium-term, investments in specialized facilities could be developed by the private sector, but there is no incentive to do so now given the substantial public subsidy to specialist physicians operating out of public hospitals. 2.27 One way of redirecting resources away from tertiary care is to move toward full (or close to full) cost recovery in tertiary institutions for items not in a basic package and for those which could be provided at lower level facilities. This would involve differentiation between fee schedules for secondary versus tertiary hospitals and would provide incentives to seek care at lower levels of the system. Rigorous collection efforts should also be stepped up. And, more appropriate "revenue" sharing between public hospitals and the private physicians using their facilities for their private patients is also warranted. That is, government should reduce the implicit subsidies to these physicians. Government should also consider limiting additional capital investment for tertiary institutions, including the acquisition of sophisticated expensive medical technology. 4. Introducing measures to increase efficiency and contain costs 2.28 Under any of the financing options pursued--even the present one--health care provision will continue to be a mix of public and private sector. For example under Options 2 and 3, health vouchers for the poor should be valid at either public or private providers. Preferred provider contracts could be negotiated between the government and private GPs to serve the poor in some remote rural areas, where they are frequently the closest provider. By the same token, most inpatient care would continue for some time to be provided by 'he public sector, even though for insured persons it would be financed increasing by either out-of-pocket expenditures or insurance. Therefore, government should introduce measures to improve the incentives to make the health care delivery system--both public and private-- more efficient, and to contain costs. 2.29 Public sector provision. In the first instance, government should immediately take steps to improve the efficiency in the way the public sector provides services. Technical efficiency gains28 in the Jamaican public health system can be found through better utilization of existing inputs. 28 Technical efficiency refers to the extent to which choice and utilization of inputs produces a specific health output, intervention or service at lowest cost. Allocative efficiency, on the other hand, looks at the distribution of resources among a number of competing uses (e.g. tertiary versus secondary or primary care). 20 2.30 The structure of the public health system--further rationalization and decentralization. Due to the observed shift in demand for private outpatient care, under-utilization and excess capacity in selected areas of the public sector is evident. Although explicit rationalization took place in the mid- 1980s with the conversion of a handful of secondary (Type C) hospitals into clinics, there has been de facto rationalization by the closing of some 45 health centers over the past decade. Further rationalization of physical structures and manpower staffing requirements is needed in Jamaica.29 In addition to the closure of facilities (especially those in rented spaces), other options include their sale or lease to the private or NGO sector. And although several of the smaller secondary hospitals have low occupancy rates, there is a case for considering their refurbishment as a priority at the hospital level on the grounds of cost-effectiveness discussed earlier. Rationalization of facilities should systematically take into account catchment population, as well as other facilities offering similar care in the same catchment area--including the private sector. Further rationalization would make more resources (human and financial) available to be concentrated in underfinanced areas, including improved quality services for those unable to afford private doctors' visits. 2.31 Decentralization and increased autonomy of key facilities such as hospitals. Decentralization away from central MOH control and enhanced autonomy at one extreme could mean total privatization of the public sector delivery system. However, efficiency gains can also be realized by converting public hospitals into semi-autonomous agencies or parastatals (an option which Tunisia recently followed). With more financial and managerial autonomy, hospitals would be less constrained by public sector procedures in managing budgets, hiring and firing of staff. The authority to retain one hundred percent of revenues collected would also give hospital managers more flexibility for deploying resources where most needed. And, authority to purchase inputs, such as drugs, could lower costs (see section on pharmaceuticals). Already, Jamaica has begun to divest non-health support services which appear to have at least improved quality and/or reduced costs (Box 2.3). In exchange for greater autonomy there would be a need for greater accountability, including putting in place appropriate auditing procedures. Information regarding key indicators of health care quality, coverage and access would also be needed at different levels--community, facility and central ministry--to ensure minimum standards. And, the issue of consultants' right to not only admit their private patients, but have free rein over the deployment of public resources in the interests of private patients also needs serious examination. For example, consultants could be required to contribute directly to hospital expenses in cash, or in kind with additional services provided during periods of greatest shortage such as evening shifts in emergency wards. An important element of decentralization would be the elimination of the dichotomous organizational and managerial structures that presently are in place for primary and hospital level care. Equally important will be the rapid implementation of plans to improve the referral system. A functioning referral system will facilitate the shift of selective services that are currently provided at the tertiary level to lower levels where they could be provided at lower cost. 2.32 Adequate provision of inputs is crucial to efficient publicly-provided care. However, the levels needed should be consistent with priority interventions included in the basic package, and reflect where those interventions are delivered most cost-effectively. 29 In addition to examining the appropriate mix of manpower (see next section), it is probably not advisable in most instances to re-staff facilities that have already been closed. 21 2.33 Manpower. Given the existing imbalance in manpower (i.e. excess capacity in certain areas and shortages in others) the present mix and levels of health manpower on the establishment list need to be critically reviewed. This exercise will be even more critical should the government proceed to prioritize interventions to be included in a basic package. Sufficient numbers and types of nurses perhaps is the most critical area. Despite MOH policy of increasing the number of nurses trained, a shortage of nurses results from both remuneration levels and poor working conditions. Safety on the job has been a recent concern; lax security in public hospitals has resulted in gang warfare spilling over into wards. Over the past year, the government was brought to the negotiating table with nurses due to strike action; salary increases were awarded. Perhaps what matters more is the improvement in their working environment, not only safety, but the availability of complementary inputs for delivering care (i.e. drugs and supplies, properly functioning equipment). Moves to decentralize managerial and financial authority from central headquarters to Box 2.3 Divestment of hospital support services As part of its strategy for rationalizing health services, the MOH has decided to divest--or contract out- -non-clinical services at selected hospitals. The ministry has selected four types of "hotel" services for potential privatization: laundry; catering; cleaning and portering; and, security. By using private providers, the MOH hopes to improve both the quality of these services and the efficiency with which they are provided, thus maintaining reasonable costs even with overheads and profit built into the private firms' price. Improving the quality of these hotel services, which are highly visible to patients, will also help the MOH to justify the higher user fees being charged for public hospital services. Furthermore, by reducing the burden of managing these services, the MOH hopes to facilitate improved management of clinical services. In 1987, contracts for cleaning and portering services at the three Kingston-area public hospitals (KPH, Victoria-Jubilee and Bustamante Children's Hospital) were signed. However, mechanisms for monitoring and evaluating these services were loosely worded and ineffectively implemented, and the quality of services provided was unsatisfactory. Consequently, in 1993, the MOH initiated a program to develop and implement more effective contracting mechanisms for private sector delivery of selected services. Spanish Town Hospital was selected as the pilot site. The first contract to be executed at Spanish Town covers cleaning and portering. Guidelines were established for effective contract design, based on models used in Britain and other countries with comparable experience. The contract, which began on October 1, 1993, details schedules and methods to be utilized for each type of service to be provided by the contractor. The contract also requires that the firm provide a monitoring officer to oversee all work activity, and includes monitoring guidelines. The response to the new service has been positive. In questionnaires and interviews conducted for the six-month evaluation, the majority of staff and patients reported that they were satisfied and that there have been tremendous improvements in quality. As a result, MOH plans to undertake new contracts at the three Kingston-area hospitals. As of June 1994, fees for the contracted-out cleaning and portering services were 25 percent higher than the hospital's previous costs. This difference reflects the increased scope and quality of services, and is also attributable to inflation. Recently, the contractor has negotiated an increase in its monthly 22 fee to further counter losses due to inflation and the cost of additional services being provided. This increase will be submitted to Cabinet for approval. In the meantime, a mechanism is being developed for itemizing input cost prices in future contracts, to facilitate indexing fee increases to rising costs. The second contract at Spanish Town Hospital, begun in February 1994, provides for privately managed laundry services. As with the cleaning contract, the response from both the public and the hospital staff has been positive. Prior to this, the hospital was unable to process the volume of laundry required for its basic services. As a result, patients were required to bring their own bed linen and pajamas, which were not adequately sterilized. A high volume of sheets and gowns were also lost to theft. More seriously, operating room linen was frequently unavailable, necessitating the rescheduling of surgical procedures, thus increasing operating room costs. The new contract provides an adequate supply of linen to the entire hospital. In addition, measures have been taken to reduce theft and loss resulting from chemical damage, which should help to achieve some cost savings. It is expected, however, that the cost of the laundry service, which was negotiated on a per pound basis, will be higher than before --simply because the hospital's previous service was inadequate. The MOH has also made substantial progress toward contracting out catering services, the third item on its list of services to be contracted out. The Ministry developed a detailed procedures manual which is critical for ensuring compliance with the special nutritional requirements of hospital food services. At this stage, contractors have been prequalified, and will be asked to submit full proposals shortly. As with the laundry, the Ministry hopes that the new contract will achieve cost savings by reducing theft, thus countering some of the additional costs associated with upgrading quality of services. Source: USAID-supported Health Sector Improvement Project and the Latin American Health and Nutrition Sustainability Project. facilities could result in improvements in the work environment and in the establishment of work incentives. Shortages of hospital physicians--especially specialists--are less a problem, thanks to the large implicit subsidies they are able to reap. Any reduction in these subsidies (as recommended above) should take into account a facility's ability to retain doctors. Appropriate incentives to keep physicians--especially those most active in delivering interventions in the basic package--will need to be discussed. Such discussions should actively include the private sector (e.g. Medical Association of Jamaica). 2.34 Pharmaceuticals. Government is no longer the major supplier of drugs in Jamaica; private pharmacies and private expenditures dominate the sub-sector. However, the public sector through the Health Corporation Limited (HCL) could potentially introduce substantial competition in pharmaceutical supply. The public sector should procure only generic drugs on a limited Vital Essential Necessary (VEN) list and refrain from purchasing brand name drugs (unless generics are unavailable). HCL has the expertise to procure drugs using international competitive bidding procedures, thereby obtaining favorable prices. In addition, HCL could aggressively market sufficient quantities of generic drugs to hospitals with autonomous budgets and purchasing authority. This could pose serious competition to the recently liberalized private pharmaceutical market, where hospitals no doubt turn now when supplies are insufficient from government stores. In parallel, the government should also support the rational use of generic or least cost drugs, especially for major chronic conditions. Information on cost-effectiveness of different drugs (especially generic alternatives) should 23 be included in treatment guidelines for major chronic conditions and widely disseminated to both public and private physicians and pharmacists, and to patients. Government also has a regulatory role to play with respect to efficacy and safety. Although the government currently requires that drugs brought into the country be registered, there is less legislation concerning dispensing expired drugs. There is anecdotal evidence that expired antibiotics are being sold by private pharmacies. At worst, these drugs are potentially toxic and harmful; at best, ineffective, but in any case, an inefficient use of resources. 2.35 Maintenance. The return to government investment in facilities and equipment has been undermined by insufficient budgets for both preventive and routine maintenance. Increasing public resources is critical in order to prevent build up of deferred maintenance until it requires major capital expenditure (such as the IDB's Health Services Rationalization Project--HSRP). Increased resources for maintenance should be targeted to priority interventions or facilities. There has been discussion of transferring the responsibility of equipment and plant maintenance to the Health Corporation Limited as a means of attracting skilled technicians--or to sub-contract with the private sector--to carry out such work. 2.36 Cost contairnent. Improved management of public health services contributes to containing costs, but the government has an important role to play in setting incentives to keep private health care costs down. Promoting diversity and competition among providers, coupled with better informed consumers of health care, can improve cost containment. 2.37 Containing costs depends greatly on the type of method used to reimburse private providers. Health maintenance organizations (HMOs) or capitation schemes are preferred over third party insurance with open-ended fee for service reimbursement. Therefore, when considering the various types of financing options, explicit consideration should be given to the effects on the structure of the health insurance industry. As noted above, the option of doing nothing would lead to the further escalation of costs because private fee-for-payment service would probably spread. Under other financing options, but especially the third one which recommends mandating health insurance, encouragement of health maintenance organizations through tax incentives and even government purchase of such a plan for its civil servants could help to keep health care costs down. Competition for patients under various health insurance plans would help to ensure that quality was not being compromised to keep within capitated amounts. 2.38 Although many consumer purchase health care with their own money, additional comparative information about costs and benefits may improve competition. For example, provision of information on the premia to cover a basic package and performance of providers as offered under various plans could encourage shopping between plans. Presently, it is very difficult to obtain information from insurance companies on their health insurance premia and benefits. Information on the cost- effectiveness of drugs--especially on generic alternatives--would apply pressure on private pharmacies to restrain mark-ups. 2.39 Finally, government can also keep costs in check by regulating the introduction of new medical technology, especially for equipment. Screening of proposed medical equipment purchases with public monies should restrict more expensive high-tech items and be limited to those appropriate for delivery of interventions in a basic package. Similar kinds of review are warranted for new treatment regimes 24 or drugs to not only ensure their efficacy and safety, but cost-effectiveness (especially if paid for with public funds). 5. Redefining the Ministry of Health's role 2.40 The first four recommendations together imply a very different, but important, role for the central Ministry of Health. Increased autonomy for public sector providers, as well as the potential purchase of private care with public funds (much as is done now for civil servants through private health insurance), plus any mandates concerning what kind of package should be covered by health insurance, would require that the MOH play less of a managerial role and more of a regulatory role. Developing this function of the MOH and strengthening information systems at different levels of the public health care system is the final element in this set of recommendations. 2.41 Information needs. In the first instance, should government undertake major policy reform in the health sector, there will be a critical need for information to guide policy makers about policy choices and their tradeoffs. Costly decisions can be made on the basis of poor information. A large amount of data is collected from various sources. In addition to household data from the Survey of Living Conditions, information on health status and utilization of health care services is collected by the Health Information and Epidemiology Units. Vital statistics are officially obtained by the Registrar General's Department, which produces crude birth and death rates of questionable accuracy, especially for some age groups. And, despite sophisticated financial management systems recently installed in the Ministry and in some of the hospitals, there is a serious deficiency of data collected concerning the cost of care. Totally lacking has been any collection by the MOH of data on the magnitude of private sector provision of care. Despite the wealth of information, compilation and analysis of data within the MOH has been weak. Although strengthening health information systems is recommended, where and how that information is collected and used is also important. While the central ministry may need certain types of data to support a change in its role as regulator, facilities which are responsible for health care delivery will also need information on indicators such as cost and quality of care. Finally, although there is a Health Planning Unit within the MOH, the planning function has virtually disappeared over the last decade. Here again, depending on the amount of delegation of managerial authority to local levels, a new role for any planning unit will need to be considered. Overseeing the deployment of health manpower should have less importance if facilities are able to more directly control staffing decisions; setting standards and norms for training or licensing health workers may be a more appropriate role. Another function for planning would be monitoring the effectiveness of ongoing health programs and changes in health status; and, if required, recommending changes to a basic package. 2.42 Regulatory functions. The recommendations above imply a much more active regulatory role for the Ministry of Health. The institutional capacity to establish standards, license and monitor care providers, enforce any changes in legislation will need to be enhanced and the skill mix of the present staffing re-examined. 2.43 Managerial capacity in implementing change. Once policy decisions are taken, there is an even more imperative need to follow through with implementing them. Unfortunately, in the current organizational structure of the MOH, change is not easily embraced. There are two distinct forms of 25 organization co-existing within the MOH. On the one hand is the civil service hierarchy with its legal mandate for overall management and budgetary control. On the other is the technical hierarchy guiding the content of work carried out by professional staff and advising on health policy matters. It is no secret that at times these two structures have had "an uneasy coexistence". 30 Moreover, the presence of the two at times has facilitated resistance to any change.31 The difficulty of the technical and administrative civil servants to reach consensus and move forward with recommendations for policy is evident from the large number of proposals that have come forward during the 1980s and early 1990s for alternative financing and organization (e.g. decentralization) of the public health care system. This division of authority has also had a negative impact on the effective management of the public health care system. Unfortunately, despite the fact that the MOH has been recently reorganized and corporately planned, its dual structure remains essentially unchanged. As countries that have embarked on reforming health care systems can attest, political will strongly supported by a consensus among technical staff and civil servants is imperative for success. G. Next steps 2.44 Any transformation of the Jamaican health care system is bound to occur over time. Reform is a permanent process, not a once-off effort. It requires both the capacity and political strength to continuously review and revise health care policy. Nevertheless, there are a set of critical actions which, based on the above recommendations, should be considered in the short-term (i.e. over the next 1-3 years). Many of these involve changes to the way in which health care is financed; other immediate steps call for actions to improve efficiency. Table 2.1 is a matrix which summarizes the set of recommendations offered, key actions and their proposed timing. 30 Cumper, 1993. 31 This division of responsibility between administrative and technical entities is evident throughout the public health care system, making effective management almost impossible. An example at the hospital level is the demarcation between the Chief Executive Officer and the Administrator versus the Senior Medical Officer and the Matron. 26 Table 2.1 Key recomnendations and actions for the short and medium term Recommendation Short-Term Medium-Term 1. Define basic package * prioritize interventions on basis of contribution to * continued monitoring of the reducing burden of disease and cost-effectiveness disease burden and adapting of * reconsider scope of publicly-funded services basic package to reflect changing (e.g. increase health promotion) health care priorities 2. Facilitate financing of the * establish/enable financing mechanisms (e.g. . package mandate health insurance, health vouchers) 3. Reduce publicly-financed * increase cost recovery levels and improve * facilitate private sector share of tertiary care collection at tertiary facilities development of facilities for * set differential fees at secondary facilities delivery of specialist care * improve referral system * establish "revenue" sharing with private physicians * limit new investment 4a. Improve health sector Restructure public sector delivery system: efficiency * further rationalization of public facilities * increase financial and managerial autonomy of hospitals and health centers * possible divestment of selected * increase resources for lower level hospitals facilities * improve referral system through better integration of primary and secondary care Provide adequate provision of key inputs: * improve pharmaceutical procurement and prescribing practices * increase budget for facility and equipment maintenance 4b. Contain costs * promote HMOs through tax incentives * provide health care consumers * consider GOJ purchase of health maintenance with info on costs and provider ____ =____________________ plan for civil servants performance 5. Redefine role of central * define and strengthen regulatory function MOH * strengthen health information systems, including at facility level * improve data collection and analysis (especially cost data) 27 PART II: THE JAMAICAN HEALTH CARE SYSTEM. PASTAND PRESENT 3. HEALTH STATUS AND DISEASE BURDEN 3.1 Jamaica's health indicators are generally more favorable than those of other countries in the Latin kmerican and Caribbean region at similar levels of income. Over the last 25 years the progressive improvement in health status has brought about an epidemiological shift as increasingly more deaths are due to chronic and degenerative diseases and less from causes related to infectious and vector borne diseases. This transition reflects both an aging population due to declining fertility and mortality, and changes in risks attributable to urbanization, industrialization and lifestyle. Although, Jamaica is facing a disease profile that is increasingly "lifestyle" related, concern remains, however, about high--and preventable--perinatal mortality rates. 3.2 This chapter begins by discussing recent demographic trends and projections of the population structure over the next three decades. A profile of Jamaica's burden of disease, the combined effects of both morbidity and mortality, is offered to give a sense of scale of the health problems facing Jamaica. Patterns of morbidity and mortality are highlighted by major classification: chronic non- conmmunicable diseases; injuries; child and maternal health; and communicable diseases. A brief description of existing health programs to address these sets of health conditions concludes the chapter. A. Demographic trends 3.3 Improvements in health status over the last twenty years are reflected by falling death rates (Table 3.1). The crude death rate (CDR) fell from 8.8 per thousand in 1970 to 6.8 in 1980 and to 5.1 in 199032. At the same time, drops in total fertility has reduced birth rates. The slowing of population growth over the last two decades has reflected the falling total fertility rate (TFR). The TFR declined from 5.5 in 1970 to 3.5 in 1983 and to 3.0 for the period 1990-9233. The crude birth rate (CBR)-- births per 1,000 population--fell from about 34 per thousand in 1970 to about 25 in 1990. The rate of natural increase (RNI) has followed a similar pattern, dropping by nearly a quarter in the period 1970- 1990. 32 The Registrar General's Department (RGD) of the Ministry of Health (MOH) is responsible for the collection and analysis of national vital statistics, including births, deaths, marriages and divorces. Unfortunately, there is known to be consistent under-reporting of births, infant deaths and deaths from injuries which in turn limits the value of these statistics for estimating reliable morbidity and mortality trends. A 1985 national household survey found that as many as 15 percent of births and 36-53 percent of infant deaths were not registered, especially those occurring within the first 6 days after birth. The underregistration problem for deaths due to unintentional (e.g. motor vehicle accidents) and intentional (e.g. homicides) injuries stems from the legal requirement for a police investigation and a coroner's inquiry before the cause of death is certified and subsequently registered. In 1981, police statistics reported 405 homicides and 257 traffic fatalities, while for the same year the RGD reported a total of 208 deaths from both causes. Although under-registration of deaths is unlikely to affect overall death rates, it is probably significant for selected age and gender groups (i.e. males 15-49). Jamaica has conducted various surveys since 1975 to trace changes in fertility, including most recently the Contraceptive Prevalence Survey (CPS) in 1993. 28 3.4 External Migration. The natural rate of increased has been dampened by significant out migration is reflected by population growth rates which are significantly lower than RNI. The trend of net migration from Jamaica that began in the 1980s has continued into the 1990s with the U.S. absorbing the lion's share. The volume of net external movements was equivalent to half of the net natural increase in several years, indicating that it continues to be an important factor in determining population size. In addition to the direct impact of persons leaving the country, half of all migrants to both the U.S. and Canada in 1991 were women and of these, 65 percent were in child-bearing ages 15- 49. This factor will also contribute to the slowing of population growth through its impact on the crude birth rate. Table 3.1 Key demographic indicators, Jamaica and selected countries Population Life TFR CBR CDR RNI Population (millions) Expectancy (per (per Growth Rate (years) 1000 1000 (percent)a pop) pop) c. 1970 1.9 68 5.5 34 9 25 1.42 c. 1980 3.5 27 7 20 0.86 c. 1990 2.4 70 3.0 25 5 19 1991: Dominican 7.2 67 3.1 27 6 21 2.2 Republic I U.S. 252.7 76 2.1 1 6 9 _ 7 0.9 Japan 123.9 79 1.5 10 7 3 0.5 Sources: For Jamaica: Health Information Unit; for others: WDR 1993. a. For Jamaica, figures are intercensal growth rates for 1970-82 and 1982-1991 respectively. For other countries, average annual growth rate between 1980-1991. 3.5 Population size and growth rates. Preliminary results of the April 1991 Population Census indicate that there were 2.366 million residents. The annual population growth rate since the 1982 Census was 0.86 percent, down from 1.42 percent in the previous intercensal period (1970-1982). Projections for the turn of the century indicate that the population will continue to grow slowly. Assuming replacement level fertility, the population in 2000 will be just over 2.5 million--well under the 2.7 million target set by the National Population Policy. By 2030, the population is projected to just reach 3 million. 3.6 In comparison with the Dominican Republic, another middle income country in the Caribbean, Jamaica fares better. Life expectancy in Jamaica is now about 70 (up from 68 in 1970), while in the Dominican Republic the average life expectancy is just 67. Life expectancy in the U.S. and Japan are in the mid- to upper 70s and the demographic transition is further along, with lower population growth rates and higher crude death rates reflecting older populations. 3.7 Analysis of age structure. The population has aged since the last Census in 1982 (Figure 3.1). The proportion of the population over the age of 18 has increased by 4 percent and comprises 58 percent of the population. The proportion of population over age 60 was about 10 percent in 1990. By 29 2030, the share of the elderly population will nearly double to 19 percent.34 The dependency ratio (the ratio of the population under 15 and over 65 to those age 15-64) will continue to fall until the year 2015 reflecting the fall share of those under 15. After 2015, the decline in the dependency ratio is reversed due to the increasing numbers of those over 65. In 1990 there were about 10 elderly for every 100 working age person (15-64); by 2030 there will be 20 for every 100 (Figure 3.2). 3.8 The population of Jamaica is roughly divided between urban and rural areas with just over a fifth (22.8 percent) living in St. Andrew, the parish surrounding Kingston. Another 15 percent lives in the neighboring parish of St. Catherine; taken together more than one third of the population lives in these two parishes (Annex II, Table 1). 3.9 Urban growth. Although the population grew at less than one percent during the last intercensal period, this growth has not occurred evenly throughout the island. Major urban areas have expanded more rapidly. The population of Montego Bay grew by nearly 20 percent from 1982 to 1991 at an annualized rate of 1.9 percent. The towns of St. Ann's Bay, Mandeville and May Pen saw annual growth rates of 1.7, and 1.5 and 1.5 percent respectively. And, while Spanish Town only grew by 0.4 percent, the neighboring satellite town of Portmore experienced a phenomenal rate of 2.3 percent annually or 25 percent between 1982 and 1991. And, while the proportion of the population living in Kingston has continued to fall from 7.7 percent in 1960 to 4.4 percent in 1991, the Kingston Metropolitan Area has expanded at an annual rate of just over 1 percent between 1982 and 1991 compared with 0.85 percent from 1970-198035. 3 World Bank demographic projections based on the 1991 population census and an estimated age structure. Preliminary Results of the 1991 Census, STATIN. 30 Figure 3.1 Population structures, 1990 and 2030 by age group and sex as % of total pop 1990 75 + 70-74 65-69 60-64 J 55-59 - 50-54 45.49 - 40-44 Female 35-39XX 0X;*Ml| UMale 30-34 25-29 20-24 15-19 L 10-14 5-9 0-4 -15.0 -10.0 -5.0 0.0 5.0 10.0 15.0 2030 --Female 75± - 70-74 UMale 65-69__ - _ _ _ _ _ _ _ _ 60-64 _ _ _ _ _ _ _ _ _ _ _ _ 50-54 40-44 30-34 25-29 20-24 - - 15-19 10-143 5-9 0-4A -4.0 -3.0 -2.0 -1.0 0.0 1.0 2.0 3.0 4.0 31 Figure 3.2 Dependency ratio, per 100 working population, 1990 - 2030 70 60 50 20 10 + _Dependency ratio . Youth ratio 0 - t . Elderly ratio 1990 1995 2000 2005 2010 2015 2020 2025 2030 2 B. Burden of disease 3.10 Based on Jamaica's cause of death data classified by age and gender, an estimate was made of the overall disease burden. A composite indicator, disability adjusted life years (or DALY), is the sum of losses from premature death (difference between age at death and life expectancy at that age) and loss of healthy life due to disability (Annex III). In 1990, just over 290,000 disability adjusted life years were lost in Jamaica or at a rate of 120 years per thousand population. The contribution of early mortality to the overall burden of disease was slightly greater than that of disability (52 percent vs. 48 percent respectively). 3.11 The burden of disease is disaggregated by three internationally recognized classifications: communicable diseases (including maternal and perinatal conditions); non-comnmunicable; and injuries. In general, as overall health status improves, it can be expected that total disability adjusted life years (DALYs) per thousand population per year falls and the distribution of the burden shifts away from a preponderance of communicable diseases and toward non-communicable. In Jamaica, non- communicable illnesses (such as heart disease and cancer) account for 60 percent of the total disease burden. Injuries (including traffic accidents and homicides) were responsible for almost one quarter. Communicable diseases made up the remaining 16 percent (Table 3.2). Jamaica is well along the way of what is termed the epidemiological transition and is most similar to industrialized countries. 3.12 By gender. Overall, more disability adjusted life years were lost among men than women (58 percent against 42 percent). There are also gender differences with respect to major causes of loss of health life. Among males, over a third of all DALYs lost in 1990 were from injuries. Non- communicable illnesses (such as cardiovascular conditions, neuro-psychiatric disorders and cancers) still accounted for over half of all DALYs lost. Communicable diseases among men were responsible for only about 12 32 percent of the total. Women, on the other hand, were more afflicted by non-communicable diseases (70 percent); injuries contributed less than 10 percent, while communicable illnesses (including maternal conditions) represented 20 percent. Table 3.2 Burden of disease by sex, cause type of loss, 1990 (percent, by row) Sex and Disease Category Outcome CommunicableD Noncommunicable Injuries Male 12.3 53.0 34.7 Premature death 16.8 53.1 30.1 Disability 7.4 52.9 39.6 Femnale 20.6 69.8 9.6 Premature death 20.1 73.7 6.2 Disability_XX X 2_1.2_ 65.6 13.2 TOTAL 15.8 60.0 24.2 Premature death 18.2 61.6 20.2 Disability 13.2 58.3 28.5 Source: Harvard Center for Population and Development Studies, Jamaica: Disease of Burden Analysis, June 1994. a. Total DALYs lost in 1990 were 290,519 or approximately 120 per thousand population. b. Includes maternal and perinatal causes. 3.13 By age. Figure 3.3 shows DALYs lost by major age groups (children under five and 5-14; young adults, mature adults and the elderly) and by gender. Among children under five, communicable diseases accounted for just over half of all DALYs, with very little difference between males and females. For males aged 5-14, injuries accounted for over one-third and for both boys and girls of this age, the share of communicable diseases falls to about one-quarter. For young adults (15-44), there is a striking difference between men and women: nearly 60 percent of DALYs lost among men is attributable to injuries, while for women the leading causes are non-communicable. For ages 45 and over, however, the leading causes of death and disability are clearly non-communicable chronic illnesses which are inherently more costly to treat. 3.14 Annex II, Tables 2 and 3 show these same age groups and rank the top ten leading causes of lost DALYs. For children under 5, perinatal conditions were the leading cause (over 30 percent of the total), followed by congenital conditions (10 percent); diarrhoeal diseases, protein-energy malnutrition and cardiovascular conditions made up the remaining top five causes. Motor vehicle accidents ranked ninth. For boys between 5-14, the leading cause was motor vehicle accidents, accounting for almost 29 percent of all lost DALYs; intestinal helminths were second (16 percent). For young girls, the pattern was reversed: intestinal problems were the leading cause (20 percent), followed by car accidents (16 percent). For men aged 1544, homicides were the leading cause of premature death or disability (35 percent). Motor vehicle accidents follow second (17 percent), while cardiovascular diseases were third, followed by alcohol dependence and cancers. For women age 15-44, pelvic inflammatory diseases are the leading cause of disability years lost. Cardiovascular diseases were the second leading cause (12 percent), followed by cancers (10 percent). Although maternal mortality rates are high in 33 Jamaica (given the generally advanced levels of other main health indicators), maternal conditions are not a leading cause of death or disability, even in the childbearing age group 15-44. In fact, it accounted for only one percent of all DALYs lost. For women (45-59), cardiovascular diseases accounted for over a quarter, while cancers contributed just under one-quarter. Among individual conditions, diabetes is the leading single cause of premature death or disability for adult women (13 percent). Cardiovascular diseases also rank first for men 45-59 (25 percent), cancers accounted for 16 percent and neuro-psychiatric conditions for 13 percent (among which alcohol dependence was the second leading cause of lost DALYs). Diabetes ranked third among individual conditions (6 percent). Among the elderly, the group of cardiovascular illnesses accounted for the bulk of all DALYs lost-46 percent for women and 39 percent for men. Cancers followed (14 and 17 percent respectively), but diabetes was the second single cause of lost DALYs among elderly women (13 percent). Neuro- psychiatric disorders, predominately Alzheimers and other dementias, accounted for about 9 percent of the total. Figure 3.3 Disease Burden by age group and sex, 1990 100 % l 60% % 40% Injuries EN oncom municable ECom municab le 20% 0 % z ~~~~t L;3 C's 0% --. -- - - 'IT k) + V r C. Emerging patterns of morbidity and mortality 3.15 In general, there has been a noticeable shift in the pattern of illness and mortality away from childhood and communicable diseases toward chronic adult diseases and accident-related deaths. Jamaica's disease pattern resembles more that found in developed countries than in other LAC countries. The emerging preponderance of chronic conditions will present a major challenge to the Jamaican health system in the coming years as the population ages. Injuries, especially among young men, are a major loss of life and the medical care needed for them is costly. Among communicable diseases, there continues to be a high rate of perinatal mortality.36 For children under five, perinatal mortality ranked as the top cause of lost DALYs (36 percent) and for all ages, perinatal deaths contributed 9 percent to years of life lost to premature mortality. 1. Non-communicable diseases 3.16 Chronic non-communicable diseases are the major cause of morbidity and mortality, accounting for 60 percent of all DALYs lost in 1990. Based on the burden of disease analysis, the top five non- communicable conditions were: cardiovascular, neuro-psychiatric, cancers, diabetes and nutritional conditions. The first four of these diseases accounted for 83 percent of DALYs lost among the population over 60. The doubling of the elderly population over the next 35 years, will increase the prevalence of those illnesses and no doubt increase the demand for their treatment. 3.17 Cardiovascular diseases. In 1990, cardiovascular diseases (including cerebrovascular disease, ischemic heart disease and hypertension) accounted for 30 percent of all non-communicable DALYs lost and 17 percent of the total disease burden. Hospital discharge records show that cardiovascular diseases increased as a cause of morbidity between 1989 and 1990 (from 26.2 to 32.3 per 10,000). In the 1991 Survey of Living Conditions (SLC), one third of those surveyed over the age of 50 reported that they were hypertensive, as did nearly twice as many women as men (Table 3.3). The prevalence of hypertension was also higher among the highest income quintile, although this may reflect better detection of the condition because of known increased use of preventive care among that group. 3.18 Neuro-psychiatric conditions accounted for the next largest share of chronic illness (about 19 percent) and 11 percent of the total disease burden. Most of the impact is from disabilities arising from substance dependencies and affected disorders. According to data from the community mental health service for 1987-1991, schizophrenia was the main diagnosis, representing 40 to 50 percent of the total case load. The nation's psychiatric hospital, Bellevue also listed schizophrenia as the leading condition. In 1991, substance abuse accounted for about 15 percent. Data for 1991 show that there were more male than female cases, and that the age group 15-34 is most affected. Perinatal period is defined as up to 7 days after birth: neonatal, up to 28 days after birth; and infant as under one year of age. 35 Table 3.3 Hypertension and diabetes, prevalence by quintile, residence, sex and age (percent) Category Hypertension Diabetes lQuintilel Poorest 8.2 1.8 2 8.0 2.2 3 _ 7.8 2.7 4 7.8 2.3 5 10.0 3.0 Sex l Male 5.6 2.0 Female 11.9 2.8 Age group 0-9 0.0 0.1 10-19 0.5 0.1 20-24 1.6 0.2 25-29 3.5 0.9 30-34 5.4 1.0 34-39 7.5 0.9 40-44 11.2 2.7 45-49 11.9 3.5 50+ 34.1 10.7 JAMAICA 8.5 2.4 Source: Survey of Living Conditions, 1991. 3.19 Cancers. Malignant neoplasms accounted for 15 percent of non-communicable diseases and 9 percent of the total disease burden in 1990. The specific types of cancer varied markedly by gender with lung, stomach and prostrate cancer most common among men. For women, breast and cervix accounted for about half of all DALYs lost. The Jamaica Cancer Registry at the University of the West Indies Medical School (UWI) has actively registered the incidence of cancers since 1958 for residents of Kingston and the parish of St. Andrew. Over a thirty year period the incidence of cancer was higher among women than men at a ratio of 1.4:1. The most important cancers in men over the period were found to be prostate, stomach and lung (Figure 3.4). Over the period 1958-1987 the trend in average annual incidence37 shows a drop in cancers of the stomach and esophagus, some decline in prostate cancer, while lung cancer appears to have leveled off, albeit at high levels. 37 Age-standardized rates. 36 Figure 3.4 Cancer in men, 1958-1987 30 25 20i O-t- - t _ . 4Prostate -Lurng 15 - ~~~~~~~~~~~~~~~~~~~~~~Stomach Oesophagus 'U 0- 1958-1963 1964-1966 1967-1972 1973-1977 1978-1982 1983-1987 3.20 For women, cancer of the cervix and breast accounted for just over half of all cancers recorded during the thirty year investigation (Figure 3.5)3, with breast cancer exceeding invasive cervical cancer. And, the proportion of cervical cancer detected in its preinvasive form has increased due to the success of screening programs (Figure 3.6).39 The rate of lung cancer in women is low and is one quarter the rate of that for men, while stomach cancer has shown a similar decline in women as for men. Brooks, S.E.H. et al., 1991(a). 39 Brooks, S.E.H. et al., 1991(b). 37 Figure 3.5 Cancer in women, 1958-1987 Breast 25% 7 ,/ / Other 48% Cervix (invasive) 20% Cervix (in situ) 7% Figure 3.6 Cervical cancer in women, 1958-1987 50 45- 40- == _ =.' / A Cervix (in situ) 25 - sixth in 1991 as a-' diagnos=s of curative visitsto governmen primary health care faCilities d (invasive) 1 5- 4 - _ = .=1 0 - -= i_............. 1958-1963 196.4-1966 1967-1972 1973-1977 1978-1982 1983-1987 3.21 Diabetes mellitus was responsible for 6 percent of all non-commnunicable diseases and 4 percent of the total burden of disease in 1990 and is estimated to affect some 120,000 Jamaicans. It ranked sixth in 1991 as a diagnosis of curative visits to government primary health care facilities and for many 38 years diabetes was included among the top ten reasons for admission to hospital. Data from the 1991 SLC (see Table 3.3) detected one in ten of persons surveyed over age 50 said they were diabetic. Reported rates were slightly higher for women than men and 3 percent among the highest income group were diabetic compared with 1.8 percent in the lowest income group--although this may reflect poorer detection than actual prevalence. The Diabetic Association of Jamaica estimates that less than half of those with diabetes are aware of their condition, despite it being fairly easy to detect. Early detection and control through diet counseling, monitoring and drugs provided at the health center level could delay the onset and/or reduce the severity and complications, as well as lower treatment costs (in 1983, diabetic in-patients experienced the longest average iength of stay when hospitalized). Undetected and uncontrolled, diabetes can lead to severe complications in the functioning of nerves and blood vessels; diabetics are also more likely to develop heart and kidney disease and strokes. Diabetes is also the leading cause of adult blindness. 3.22 Nutritional deficiencies ranked fourth among the noncommunicable conditions and contributed 4 percent of the total disease burden. Of these, anemia accounted for over a third and was responsible for disability. Among women, anenita stands out as the most significant nutritional disorder that affects maternal health. An islandwide study in 1978 indicated that, using WHO standards, 61.6 40 percent of pi Egnant and 58.7 percent of lactating women were anemic. Iron deficiencies are believed to be due to inadequate nutrient intake, low level absorption, short birth intervals and high fertility. Although the study did not find significant differences between urban and rural women, the 1989 Perinatal Mortality and Morbidity Study found that the proportion of women who were anemic did vary with socioeconomic status. Pregnant women who were married at delivery were less likely to be anemic as were women who had secondary or higher education, or those whose major wage earner was in a non-manual occupation. 3.23 Protein-energy malnutrition accounted for another third of nutritional deficiencies. Most of the DALYs lost were on account of premature deaths among the 0-4 age group. Among this age group, nutritional disorders ranked fourth after perinatal conditions and congenital abnormalities and diarrhea. Of the malnutrition reported among adults, it is conceivable that this may be misrecorded deaths due to AIDS. 3.24 More detailed nutrition data for children are shown in Table 3.4 and are drawn from the Survey of Living Conditions (SLC) and from anthropometric surveys conducted by the MOH in 1978 and 1985.41 The data for low weight for age indicate a steady decline in malnutrition levels from 1978 to 1989. Although for 1990 to 1992 an upturn is shown ranging between 8 to 9 percent, the increase is small (perhaps statistically insignificant) and it does not appear that malnutrition has worsened overall. Simmons, W. et al., (1982). "A Survey of the anemia status of preschool age children and pregnant and lactating women in Jamaica." The American Journal of Clinical Nutrition, 35. pp. 319-326. 41 The Survey of Living Conditions is a household based survey conducted in Jamaica annually since 1989. It is based on the Living Standards Measurement Survey (LSMS) developed at the World Bank. it The sampling techniques of the MOH and the SLC surveys were somewhat different, so they may niot he strictly comparable. In particular, the MOH surveys were conducted at homes during work hours during the school year, and to the extent that malnourished children do not attend school, these surveys may overestimate malnourishment. In fact, as shown above, children from poorer households are less likely to attend pre-school, thus oversampling the poor. An attempt to correct for the sampling bias in 1985 shows that low weight for age would have been 14.0% instead of 14.6%. 39 Table 3.4 Malnutrition rates for children under 5, 1978-1992 Low weight for age (percent) SLC Survey Low weight for age Moderate Severe Total MOHI 1978 15.0% MOH 1985 13.6% 1.0% 14.6% SLC May 1989 8.5% 0.7% 9.2% SLC November 1989 6.5% 0.8% 7.3% SLC November 1990 8.0% 0.4% 8.4% SLC November 1991 9.0% 0.0% 9.0% SLC August 1992 8.1% 0.5% 8.6% Source. PIOJ, "Survey of Living Conditions" various years. Note: Normal weight for age children are those over 80% of the reference standard. Moderate is a weight for age 60-80% of the standard and severe is below 60% of the standard. 3.25 Table 3.5 displays low weight-for-age by quintile for the last five SLCs. The lowest quintiles have the highest rates of malnutrition, but the relationship to economic status is not consistent. In three of the last five surveys, the fifth quintile has had higher rates than the third and fourth. Incidence of malnutrition by region are displayed in Annex II, Table 4. Although malnutrition rates improved between 1991 and 1992 in rural areas and other major towns, rates actually worsened in the Kingston Metropolitan area. The proportion of low weight for age in Kingston rose from 5.2 percent in 1991 to 8.6 percent in 1992, while for rural areas, there was a decrease from 9.8 percent to 8.8 percent. For other urban areas, the comparable figures were more dramatic--a decrease from 10.7 percent to 6.9 percent. Table 3.5 Malnutrition, by quintile, 1989-1991 Low weight for age, children Under 5 years (percent) SLC Survey Quintile r All Jamaica 1 2 3 4 5 May 1989 10.2 10.8 8.1 6.9 9.1 9.2 November 1989 8.1 11.0 5.4 6.1 2.7 7.3 November 1990 12.2 3.7 11.1 9.8 4.5 8.4 November 1991 11.3 11.5 7.5 3.2 8.1 9.0 August 1992 14.5 5.3 6.7 6.0 X 7.3 8.6 Source: PIOJ, "Survey of Living Conditions Report", various issues. 3.26 Within Kingston, however, the problem of undernutrition is one which displays a definite spatial pattern; there are areas which have been consistently identified as having higher malnutrition levels. In fact, there has been a reported increase in the percentage of children admitted to Bustamante Hospital for Children for malnutrition. In terms of the age composition of children under-five experiencing malnourishment and living in the greater Kingston area, there has been a noticeable shift toward younger ages. Data from the Bustamante Children's Hospital show that in 1987 a third of all 40 cases were between 6 and 11 months, while 43 percent were between 12 and 23 months. By 1991, however, the onset of malnutrition appeared more frequently in younger children, 44 percent were between 6 and 11 and 29 percent between 12 and 23 months. This is clearly tied to the weaning period. 42 2. Injuries 3.27 Injuries now account for a quarter of all DALYs lost. In 1990, one out of ten DALYs lost was due to homicides43, while motor vehicle accidents represented another 9 percent of the total burden of disease. In terms of morbidity, injury and poisoning ranked second (after normal deliveries) as the leading cause of discharge for inpatients from major general hospitals in 1991. Of these, over one quarter were due to vehicle accidents (Table 3.6). Stabbings and gunshot wounds accounted for another 15 percent, followed by assault (11 percent) and poisonings (6.7 percent). Table 3.6 Distribution of injury, by cause, 1991 (percent) Cause of injury | Motor vehicle accident 21.4 Other vehicle accident 4.9 Stabbings 13.0 Assault (including rape) 10.6 Poisoning 6.7 Gun shots 2.2 Legal intervention 0.4 Other" 40.8 Total 100.0 Source: Fox, memorandum, November 1993. 1. Includes accidental injuries due to falls, fires, natural disasters and self-inflicted injuries. 3.28 Motor vehicle accidents. Unintentional deaths due to traffic accidents (involving drivers, passengers and pedestrians) have also risen from 283 in 1985 to 444 deaths in 1991 and falling off slightly to 428 in 1992--a third above the 1985 level. The number of traffic deaths has risen from 13.7 per 100,000 in 1980 to 16.9 in 1989.44 For the period 1985-1992, over 40 percent were pedestrians and on average one third of those were children under 15.4 Alcohol and/or drug use does not appear 42 Anderson, Patricia. "The Incorporation of Mothers and Children into the Jamaica Food Stamp Programme" Jamaica Poverty Line Project, Working Paper No. 6, Planning Institute of Jamaica, February 1993. 3 As noted earlier, deaths from accidents seldom get recorded in official death registrar. For example, 1981 police statistics reported 405 homicides and 257 traffic fatalities, yet the Registrar General's Department recorded only 208 deaths from all accidents and injuries. The burden of disease analysis was based on deaths reported to the RGD and corrections were made to the data for injuries (motor accidents and homicides) based on police records. " Simmonds, 1993. 45 Fenton, 1993. 41 to be among the leading reported causes of accidents, while poor driving judgment (poor overtaking, speeding) accounted for 75 percent of accidents. For every motor vehicle death during a five year 46 period 1985-1989, there were almost nine injuries, three of them serious. The majority of the accidents occur in densely populated areas of the island; over half (53 percent) occurred in St. Andrew parish surrounding Kingston. 3.29 Homicides. In terms of mortality, there has been a steady increase in the number of reported homicides over last two decades. In the years 1973-1979, there was an annual average of 323 reported murders; from 1981 to 1986 the average rose to 433 per year.47 In 1991, there were 561 murders reported by the Jamaican Constabulatory, up from 542 in 1990. For 1993, a local leading newspaper reported that there were 653 murders; in the four and a half months of 1994, the same source reported 48 266 murders 3. Infant and child health 3.30 Infant mortality is a performance indicator that is sensitive to both socioeconomic conditions and access to health care. Although many sources cite an official infant mortality rate of 15 per 1000 live births, it is a commonly accepted that there is significant under-reporting of infant deaths, especially in the perinatal period (up to 7 days after birth). A 1989 Perinatal Mortality and Morbidity Study estimated that adjusting for this under-reporting would raise the infant mortality rate to 35- 40/1000 live births.4 In 1991 the infant mortality rate was estimated at 25.5 per 1000 live births, down from 29.8 in 1990 based on births occurring in government health facilities (which account for about 80 percent of all births).50 3.31 Although Jamaica is undergoing a transition to a disease profile that is increasingly lifestyle related, there remains considerable room for improvement of perinatal health. Perinatal conditions account for 44 percent of all years of life lost due to premature mortality in the under five age group and 36 percent of all DALYs in young children. Congenital abnormalities ranked second accounting for about 10 percent of DALYs in that age group. 3.32 The main factors that affect infant survival in the neonatal period (up to 28 days) are birthweight and the quality of antenatal and perinatal care. Studies have shown that over 95 percent of pregnant women in Jamaica have had at least one antenatal visits; moreover, the vast majority deliver in hospital (even among the poorest quintile). A forthcoming study from the MOH found that the 46 Road Traffic Police Statistics, 1992. Swezy, 1987. 48 The Gleaner. March 6, and May 13, 1994. Note that all these figures are substantially higher than officially registered by the Registrar General's Department. University of the West Indies (1989). Jamaica Perinatal Mortality and Morbidity Study, Final Report, Department of Child Health, Mona, Jamaica. PIOJ, Economic and Social Survey of Jamaica, 1991 42 majority of infant deaths occurred not only during the first month, but within the first week of life. Given the high proportion of births delivered in hospital, this finding points to the need of improving perinatal care, specifically inpatient obstetric care. The 1989 perinatal study found that the major cause of perinatal deaths was intrapartum asphyxia which is readily preventable through improvement in the provision of services for the management of labor, delivery and resuscitation of the newborn and training of staff to recognize and manage such problems. 3.33 Infant and child morbidity. The main causes for hospitalization of infants under one were conditions related to perinatal period and gastroenteritis (e.g. diarrhea), followed by respiratory illnesses. For children between 1 and 4 years, respiratory illnesses ranked first in 1990 followed by injuries and poisonings and gastroenteritis (Table 3.7). In terms of disabilities, congenital abnormalities accounted for 22 percent in the age group 0-4, followed by injuries (17 percent), respiratory diseases (7 percent) and nutritional deficiencies (5 percent). Diarrhoeal diseases, while a frequent reason for hospitalization, was negligible as a cause of disability (perhaps because it is recorded as a secondary symptom of nutritional deficiencies). Table 3.7 Hospital inpatient discharges, children aged 14, 1989-1990 by first listed diagnosis, per 10,000 population Rank in First Listed Diagnosis Rate per 10,000 population 1990 1989 1990 1 Respiratory infections 100.0 91.9 2 Injury and poisoning 80.0 86.4 3 Gastroenteritis 79.5 49.9 4 Congenital abnormalities n.a. 11.6 5 Diseases of the nervous system n.a. 8.9 6 Diseases of the skin 9.7 n.a. 7 Appendicitis/hernia 9.2 n.a. Source: MOH, Health Information Unit. n.a. not available or not ranked in 1989. 3.34 Diseases of the childhood cluster (e.g. measles, diphtheria, polio, tetanus etc.) are negligible in terms of DALYs thanks to generally high immunization coverage .51 Table 3.8 displays immunization coverage for target population under age one from 1987 to 1993. Immunization coverage improved for all injections up to 1990. In 1990, coverage rates for OPV, DPT and BCG were between 85 and 98 percent. Measles vaccinations rose to about 77 percent in 1991. Data for 1993 show a noticeable drop in all vaccinations, although it should be noted that these statistics cover only public health centers and are probably an underestimate because they exclude vaccines received through private clinics. In terms of specific vaccines, the relatively low coverage of measles should be a cause for continued concern. Over the past 15 years, there have been major measles outbreaks (in 1978, 1981, 1982 and in 1989/90) 51 Within the first year of life, infants should receive vaccines for BCG (against tuberculosis), measles, oral polio (OPV), and three doses each of diphtheria, tetanus, pertussis (DTP). DTP and OPV booster doses should be given at 18 months of age, while a second DTP booster is required before entering school. Rubella vaccine is given to prepubertal girls and women in reproductive ages. 43 involving thousands of children. Immunization coverage by income quintile appears to be fairly even, indicating that immunization efforts have been successful in reaching the poor (Annex II, Table 5). In fact, it is notable that in 1991, rural coverage rates, with the exception of BCG, were higher than urban rates. Table 3.8 Immunization coverage in public clinics, children under 1, 1987-1993 (percent of target population completely immunized, by vaccine) Vaccine 1987 1988 1989 1990 1991 1992 1993 DPT 81.4 82.1 83.0 85.7 84.7 82.3 79.4 OPV (polio) 81.9 82.8 81.2 86.0 85.7 74.2 81.6 Measles 44.5 56.4 60.5 64.8 77.1 63.3 63.4 BCG 92.1 95.7 97.3 97.8 94.4 85.4 921 Source: Health Information Unit. Note: these figures exclude immunizations delivered through private clinics. 4. Maternal conditions 3.35 As noted above, maternal conditions do not figure prominently in the major causes of death and disability, even among women of childbearing age. Nevertheless, maternal mortality in Jamaica is high compared to the weighted average in other middle income countries. Current estimates place maternal mortality at 10.2 deaths for every 10,000 live births. A 1981-83 retrospective study found that the most common causes of maternal death were: hypertensive diseases of pregnancy (26 percent); hemorrhage (20 percent); ectopic pregnancy (10 percent); pulmonary embolus (8 percent); and sepsis (8 percent).52 Jamaica has an unusually high and chronic problem of hypertensive disorders of pregnancy which include pre-eclampsia (characterized by high blood pressure, generalized swelling and excess protein in urine) and eclampsia. Most of the causes of maternal mortality are preventable by appropriately managed care during delivery. Obviously, efforts to reduce related perinatal mortality would also reduce maternal death. 5. Communicable diseases 3.36 Although communicable diseases have receded among the leading causes of mortality and morbidity and mortality in Jamaica--net of maternal and perinatal conditions, they account for only 10 percent of all DALYs lost in 1990--there are serious signs that sexually transmitted diseases, including AIDS, is a growing problem. One quarter of all DALYs lost to communicable diseases are from sexually transmitted diseases (excluding HIV/AIDS). STDs are most prevalent among the older teenager and young adults populations. Pelvic inflammatory diseases (PID) among women accounted for the bulk of DALYs lost to STDs. Among the incidence of selected infectious diseases reported in Jamaica, sexually transmitted diseases (STDs) ranked first in 1992 (Table 3.9). These figures only include a small subset of all STDs. It is estimated that there are at least 250,000 cases of the eight most prevalent STDs each year. In addition, there is a high and increasing number of complications arising 52 Walker, G. Ashley, D. McCaw, A. er al., Maternal Mortality in Jamaica, Lancet, 1986;i:486-488. 44 from congenital syphilis in newborns. Moreover, there has also been a rise in penicillin resistant strains of gonorrhea, making effective control of this diseases more difficult. Among diagnoses from public heath center facilities, STDs have shown an increase from 3.4 percent to 5.5 percent of visits 1988-1991. In part, this increase is due to improved detection and treatment from the recently expanded network of STD clinics. 3.37 A special type of STD is the human immunodeficiency virus or HIV, the causative agent for AIDS. Although AIDS can also be spread through blood infusions and through intravenous drug use, most of the HIV infection is sexually transmitted. In fact, selected STDs are known to be risk factors for transmission of HIV. The burden of disease analysis indicates that DALYs lost to HIV/AIDS is less than one percent of the total. However, this figure is probably underestimated because of the general phenomenon of under-reporting of AIDS cases. The total number AIDS cases detected in Jamaica since 1982 (as of December 1993) was 669, of which 381 have died. Of the total number of reported cases, approximately two-thirds were male and one-third female. The majority of cases were reported in the age group of 30-39 years for men, and 20-29 age group for women. Although the male/female ratio for reported AIDS cases is 1.8 to 1, HIV is predominantly spread through heterosexual transmission and therefore, potentially by pregnant women to their fetuses. All parishes had reported at least eight AIDS cases. A major concern is that the incidence of new AIDS cases is rising rapidly; the number in 1991 was more than double the previous year (Table 3.9) and the incidence in 1993 at 236 new cases was again more than double 1992. Although the prevalence of IiIV is low-- approximately 0. 1 percent of the population--the AIDS epidemic could have significant effects on Jamaica's health and socio-economic status if the stable rates of HIV within the general population grow as they have among individuals with high risk behaviors in Jamaica. For example, the HIV prevalence among attendees of STD clinics was between 0. 1 percent and 0.3 percent for 1986 and 1987. By 1990, that figure had reached 3.1 percent and is expected to continue to rise. Based on a sample of commercial sex workers (CSW) in Kingston, twelve percent carry HIV, compared with a national average among CSWs of about 1 percent. Given the high rates of STDs, high rates of alcohol and drug abuse and substantial numbers of migrant workers (a known risk factor elsewhere in the world) in Jamaica, the potential for an explosion of HIV is high. Table 3.9 Incidence of selected infectious diseases, 1989-1992 DISEASE Incidence (# of reported cases)_Incidence per 100,000 1989 1990 1991 1992 1989 1990 1991 1992 STDs n. a. n.a. 26,330 28,059 n.a. n.a. 1079.6 1146.2 Gastro-enteritis 12,756 13,854 14,669 23,401 532.9 576.4 619.9 956.0 Febrile Illness 14,146 12,068 9,413 12,043 591.0 502.1 397.8 492.0 Measles 5,726 7,707 317 | 241.1 320.7 13.4 Rubella 7 18 273 32 0.3 0.8 11.5 1.3 Leptospirosis 441 120 231 246 18.4 5.0 9.8 10.0 AIDS 64 62 134 86 2.7 2.6 5.7 3.5 Tuberculosis 104 _ 123 121 4.3 5.1 5.1 4.5 Typhoid 18 209 21 27 0.8 8.7 0.9 1.1 Source: ESSJ, 1992, EPI Unit, MOH. 1. Excluding AIDS and including only gonorrhea, syphilis and non-gonococcal urethritis. 45 D. Factors producing illness and health 3.38 Understanding the risk factors that produce illness or those that preserve or restore health is important for improving health status. In addition to genetic and biological factors that may predispose one toward good or poor health, there are other determinants of health. Environmental factors, such as sanitation and occupational hazards have an affect on health outcomes, as do cultural and personal behaviors (e.g. tobacco and alcohol use, breastfeeding, consumption habits). Figure 3.7 Incidence of reported illness, by age and sex, 1989 (one month prior to survey) 35 30 25 20 UFemales 1 5 ElLL Males 15 10 0-5 6-13 14-29 30-49 50-59 60+ age 3.39 Socio-economic factors are also potential factors that have an impact on health status. The reported incidence of illness was analyzed by age, sex, income, education and location using data from the 1989 Survey of Living Conditions.53 In the month prior to the survey, 14.5 percent of Jamaicans reported an illness or injury (Figure 3.7). There was a strong correlation between age and gender. Preschool children and the elderly (over 60) had the highest rates. School-aged children and adults between 14 and 49 had lower rates. Adult women reported higher rates of illness; a woman of 60 was three times as likely to report an illness as a woman aged 14-20. For men, incidence rises more slowly with age. Education was found to be a the most important socio-economic correlate of an adult reporting an illness (Figure 3.8), while income levels were not a significant factor explaining the incidence of reported illness. 3.40 Finally, medical interventions and health programs can help restore health (curative) or prevent serious illness from occurring in the first place. The present status of key programs (most of them 53 Gertler, et al., 1993. 46 public sector) that currently exist to deal with the leading causes of poor health or premature death are discussed on the basis of major disease classifications. Figure 3.8 Incidence of reported illness, age 14 and older, by education, 1989 (one month prior to survey) 11 + 10 0 - 8 6 0-5 0 5 10 15 20 25 30 percent E. Major Health Programs 3.41 Chronic (non-communicable) Diseases. Although non-communicable diseases account for 60 percent of the DALYs lost, strategies for addressing these illnesses (e.g. through the promotion of healthy lifestyles) are not well developed, especially in the public sector. The NGO community plays a more active role in health promotion (e.g. the Jamaican Heart Foundation, the Diabetes Association). A Committee on Chronic Diseases, involving the public and private sectors, has been established although for many years it has met infrequently. In terms of treatment of chronic conditions, the general impression is that many are detected late and arise when there are serious medical complications (e.g. diabetes). Case management is also poor, especially with respect to the rational prescription of drugs. Despite there being relatively cost effective drugs for many of the major chronic ailments in Jamaica (e.g. diabetes, hypertension), physicians frequently prescribe too many or expensive brand name drugs. In turn, for patients who cannot afford to purchase a complete cycle of recommended drugs (and frequently from a private pharmacist when the hospital or health center dispensary is out of stock), compliance is low. 3.42 Mental health. Care of the mentally ill in Jamaica was initially provided by the island's only mental institution, Bellevue Hospital. Psychiatric wards were later established at Cornwall Regional Hospital and the University Hospital. Beginning in the 1970s, community mental health services began to be offered through the primary care network and Community Mental Health Officers. Hospitals are the main source of referral to community level care. In the early 1990s, the case load of the 47 community mental health program was over 8,000 cases, with approximately 2,300 new patients each year. Bellevue Hospital is a tertiary care institution with 1,500 beds providing treatment and rehabilitation for the mentally ill. In 1993/94, the hospital treated 6,849 outpatients and discharged 227 patients. The adequacy of mental health services is not known. 3.43 Injuries. Recently, much public attention in Jamaica has been focused on the social and economic impact of motor vehicle accidents. A major Road Safety Program was launched in February 1994 by Prime Minister. 3.44 Communicable diseases. Sexually transmitted diseases are the most prevalent communicable diseases in Jamaica. A combined national program for the prevention and control of HIV/AIDS and other STDs is administered by the Epidemiology Unit of the MOH. In 1986, only 6 of 13 parishes were equipped to treat STDs in terms of appropriate personnel, laboratory equipment etc.). Presently, there is a specialist STD clinic in each parish capital. In 1992 a manual with simplified protocols for syndromic management of STDs was developed locally and piloted among clinicians. Testing facilities have increased by 58 percent between 1992 and 1993, permitting earlier detection and treatment of STDs. The main thrust of the HIV/AIDS control program is prevention through public education and information programs. One project targeted information to repeat visitors to STD clinics, while a program for sex workers and farmworkers was launched in St. Catherine parish. The HIV/AIDS and STD programs are largely funded through donors such as USAID and Germany. Given the magnitude of the STD problem and the adverse effects on transmission of HIV, it is questionable whether this program is adequately funded. 3.45 Maternal and Child Health. Jamaica's favorable health indicators were the product of early efforts focused on primary health care. Jamaica was one of the few countries that actually went to the Alma Alta Conference in 1979 with a primary health care program on the ground. Community health workers formed a strong link between the community and the public health centers in the promotion of primary care. This program, established in 1977, was severely cutback in 1984 due to financial constraints and half of the 1,200 CHWs were laid off. Immunization and other child targeted programs are integrated. Antenatal care is also widespread in Jamaica with over 95 percent of mothers attending an antenatal clinic at least once during pregnancy. Although concerns remain about the timing and frequency, content and quality of this care and how it differs according to risk group as defined by demographic variables (such as age and number of children). This may help to account for relatively high reported maternal mortality rates. Poor, less educated, young women in the Kingston Metropolitan area are especially at risk for either not receiving any prenatal care or of having delayed their first prenatal care viSit.54 3.46 The family planning program in Jamaica is well established. The National Family Planning Board (NFPB) is a government statutory body under the Ministry of Health and holds the mandate for the promotion of family planning. Use of contraceptives among women in union has shown impressive increases from 46 percent in 1975 to 55 percent in 1989, rising to 62 percent in 1993. Recent increases in contraceptive use has been seen with condoms, largely the result of widespread promotion of condoms by the STD/AIDS program to reduce the spread of HIV.55 The NFPB successfully RAND study. 55 Contraceptive Prevalence Survey, 1993. 48 privatized the social marketing of condoms in 1993. The success of this program has been demonstrated by the increase in condom use by over 100 percent in the last five years. The increased use of contraception has also begun to show results in terms of falling fertility rates. In fact, due to the success of the family planning program, USAID has now begun to phase out financial support for the program, particularly importation of family planning commodities. The NFPB procures contraceptives for distribution to governmnent facilities. 3.47 Nutrition programns. In 1984 general food subsidies were eliminated and a variety of food programs were established, including the MOH's Supplementary Feeding Programme, the Food Stamp Program and a School Feeding Program were created. The MOH's Supplementary Feeding Program is a curative program targeted at children aged 0 to 5 who are identified as malnourished. There is a network of nutrition clinics which act as referral centers for children diagnosed as malnourished. The program's focus is both rehabilitative and preventive. The program distributes food in the form of cornmeal for porridge. The program also provides nutrition information to parents. The size and composition has fluctuated with the availability of food donations to the Ministry of Health. Approximately 6,000 children have been reached through this program. The Food Stamp Program is administered through the Ministry of Labour and Welfare and is targeted to four main categories of people who are considered at nutritional risk: (i) pregnant and lactating women; (ii) children under 5 years of age; (iii) those who already qualify for poor relief and public assistance (elderly, handicapped); and (iv) low income single or poor households. Children under six are automatically eligible by virtue of their age alone. A single registration at a public health clinic is required by presentation of a birth certificate on a day when a Ministry of Labor and Welfare person is present. Pregnant women are also automatically eligible and with a single registration at a clinic are eligible for a period of fifteen months (to include period of lactation). Means testing on the basis of self-declared incomes and some household information is used for indigent households. As of 1991/92, 300,000 individuals were targeted to receive food stamps. Food stamps are legal tender and are good toward the purchase of cornmeal, rice, powdered skim milk, dark sugar, flour and meats. A notable problem of the Food Stamp Program is undercoverage of the most vulnerable groups, especially pregnant and lactating women, because of underregistration--in part due to insufficient MOH staff to identify and register pregnant and lactating mothers and children. Finally, the Ministry of Education's School Feeding Program provides food during the school day to approximately 280,000 children from basic to secondary schools. In 1992, approximately 55 percent of enrolled students received some form of school snack/lunch, of which about half were from the poorest 40 percent of the population. As such, a significant portion of poor children remained outside the program. 3.48 Public Health. The public health activities of the MOH include both health education efforts as well as environmental health. For the latter, the MOH conducts regular inspections of food handlers in restaurants and meat and poultry processing industries. Health education activities are fragmented and for the most part take place through a collection of individual programs or projects (e.g. AIDS or family planning) and through parish specific health programs. There is, however, a Health Education Unit in the MOH which is functionally responsible for health education but it is under-resourced (there is over 50 percent vacancy rate for the number of health educator posts and the Unit does not have a computer) and many of its activities are indirectly supported by budgets of other programs. Almost all of the MOH's health education efforts have concentrated on communicable diseases and maternal and child health and much less on promoting health lifestyles in order to reduce chronic diseases. There is a National Health Education Committee which attempts to coordinate initiatives with private sector. 49 3.49 The epidemiological picture provides an indication of the kind of health services that will be increasingly demanded by the population to restore their health. It also points to areas where the promotion of good health through preventive actions is likely to have payoffs. What is evident is that there is a continuing need to maintain the earlier success of the Primary Health Care program and to improve on selected elements (notably maternal and perinatal care). At the same time, there will be an increasing volume of demand for services that affect the elderly and/or pertaining to more chronic diseases. Emerging problems, such as STDs and AIDS, cannot be ignored either. 51 4. ORGANIZATION AND UTILIZATION OF HEALTH SERVICES 4.1 The origins of the Jamaican health system can be traced to the colonial period when preventing communicable diseases was vital to protect the economic interests of plantation agriculture. In 1776 the Kingston Public Hospital was opened and in 1792 the Consolidated Slave Act stipulated that each sugar estate have a medical officer and report causes of death. The Public Health Service was established in 1867 to fight against outbreaks of cholera and smallpox. Subsequently, the Medical Organization of Jamaica was founded with forty medical districts. By the turn of the century, there were small hospitals scattered throughout the island. As a legacy of the colonial period and until the early 1970s, the hospital was the central focus of the health care system. By the late 1970s, Jamaica became one of the first countries to adopt an explicit public policy to promote primary health care (PHC). A parallel system developed with the health center as the focal point for PHC. In the decade 1972-1982, there was rapid expansion of health infrastructure with the building of health centers, albeit at the expense of the deterioration of the physical infrastructure at the secondary and tertiary hospital level. Today, the demands for health care in Jamaica are met by both the public health system, especially at hospital level (i.e. inpatient) and increasingly by a network of private providers for outpatient care (75 percent). A. The Public Sector 4.2 Organization andphysical infrastructure. The public health care sector is characterized as a highly centralized system with the MOH playing an active role in financial, technical and administrative functions. Not only does the ministry set major health policy (e.g. levels of user fees charged in public hospitals), but personnel functions throughout the health system are also controlled at the central ministry level. The MOH manages a network of hospitals and health centers which, in theory, are integrated to provide the full range of health care. In practice, however, there are two parallel delivery structures, one for primary care and one for secondary/tertiary care, each with its own administrative regions and management systems. 4.3 Primary health care comprises services that can be provided at the most peripheral level, which is also, in theory, the entry point into the health care delivery system (Table 4.1). Presently, there are 344 health centers, classified in five categories and operating in a hierarchical fashion. As the sophistication of services rises, the catchment population widens, with the referral system acting as a screening device to facilitate appropriate movement to more sophisticated levels of care. Type I health centers (numbering 181) have the least degree of specialization in terms of services offered and the smallest catchment population. Here, a midwife and two community health workers (CHW) provide 2,000 to 4,000 people with basic maternal and child health, along with home visits for mothers, children and the elderly. The Type II center caters to 4,000 to 12,000 persons, and provides basic curative, preventive and promotive services by a public health nurse, public health inspector, and visits by a registered nurse, the district medical officer (DMO) and a dentist. Type III provides curative services through a doctor, nurse practitioner and dentist. Type III centers are usually located in the district center and serve a catchment population of 12,000 to 20,000; supervisory public health nurse and health inspector are based here too. The distinction between Types III and IV centers is that Type IV are located in the main parish town and serve as the regional office. Type V centers, of which there are two--one in Kingston and a second opened in 1993 in Montego Bay--also have some specialty 52 outpatient care. In addition, there are 6 rural polyclinics with 6-10 day beds for normal maternity deliveries. Table 4.1 Public health care system, hospitals and health centers, 1991 Health Center/ Hospital Number, Personnel 1 Immediate | Services Provided Level | | Catchment Area | HEALTH CENTERS Satellite Visiting staff from Type I Underserved remote MCH (e.g. monthly HC areas immunizations) Type I 181 Midwife, 2 Community 2,000-4,000 MCH & home Health Workers population visits Type II 92 Public health nurse, Public 4,000-12,000 Curative, health inspector population preventive and Visiting Registered nurse, promotive l ______________________ doctor, dentist Type III 66 Doctor, nurse practitioner, 12,000-20,000 Curative and dentist Public health nurse population; district preventive at more and inspector office sophisticated level Type IV 4 Same as Type III Parish center More sophisticated curative/preventive Type V 1 Doctor, some specialists, Major urban areas Specialty outpatient nursing care, dentist care and PHC Polyclinics 6 Similar to Type III Rationalized Type C Type III services hospitals plus inpatient . . ~~~~~~~~~~~~~~~~~~~~~maternity block Family Planning Clinics 9 HOSPITALS Type C 11 Basic district hospital, 2-3 Parish Center, first In-patient and out- doctors with surgeon, X- referral patient care in ray and lab medicine and MCH Type B 4 Specialist doctors, nursing Urban areas, second In-patient and out- care referral patient, specialist service in at least surgery, internal medicine, OB/GYN, and l _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __________________________ ____________________ p e d ia tric s. Type A 5 Specialist doctors, full Kingston, MoBay Secondary & nursing complement final referral tertiary care; outpatient PHC for catchment pop. Chronic 4 Specialist doctors, full Kingston Chronic or I nursing complement ___________._._.._specialized care Source: MOH: Health Information Unit. 53 4.4 Over time, the aggregate number of health centers reflect both the expansion of the primary care network in the late 1970s and early 1980s and the subsequent contraction in the latter half of the 1980s and early 1990s. The numbers of centers peaked in 1984 at 374. By 1993, 45 centers had been closed, primarily due to lack of sufficient staff, bringing the overall total to 329 (Table 4.2). Most of the closures were in Type 1 (34) and Type III (12) centers. Other types have actually increased in number--Type IV (from 2 to 4) and Type V (from 1 to 2)56. Table 4.2 Number of public health centers, by type, 1981-1991 Type 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1993 1 195 198 203 206 201 191 191 191 188 184 181 172 11 86 86 88 88 88 89 89 93 87 93 92 85 III 76 76 78 77 77 77 78 66 66 66 66 66 IV 2 2 2 2 2 2 3 4 4 4 4 5 V 1 1 1 1 1 1 1 1 1 1 1 Total 360 363 372 374 369 360 362 355 346 348 344 329 Source: MOH, Health Information Unit; for 1993, MOF 1994/95 Budget. 4.5 Administration of the primary health care system is coordinated at the central level by a Principal Medical Officer (PMO). The island is subsequently divided into four regions (Southeast, Northeast, Western and Southern). Within the regional structure are situated 14 parishes. Budgets from the MOH to health centers are issued on the basis of parishes. It is also at the parish level where a Medical Officer coordinates the activities of the 47 health districts. 4.6 Secondary and tertiary care includes a network of 18 acute care hospitals, 6 specialty hospitals (including a mental, a children's and maternal hospital), and three chronic care hospitals (Annex II, Table 6). Acute hospitals are classified as Type A, B or C depending on the type of service offered and the size of catchment population (see Table 4.1). There is at least one Type C hospital in each parish, although Kingston has only tertiary or specialty facilities. Type C hospitals function as the basic district hospital which, in theory, is the first point of referral from the PHC system at the parish level. Services provided include in-patient and out-patient care in the areas of general medicine, maternal and child care. These hospitals are staffed by two or three doctors (one of which is likely to be a specialist surgeon for emergency care). In addition, Type C hospitals usually have x-ray and laboratory facilities which also cater to PHC and private sector referrals. Type B hospitals provide in- pat.ent and out-patient specialist care in at least four areas: general surgery, internal medicine, obstetrics and gynecology, and pediatrics. In theory, Type B hospitals, which are found in larger urban areas, are the second level of referral and support Type C hospitals. Type A hospitals provide secondary and tertiary services57 for the entire island and are the final referral point in the public (and 56 New construction has taken place under externally financed projects. The World Bank's Social Sector Development Project--appraised in 1988--included the construction of 8 new health centers, while the Population and Health Project built a new Type V in Montego Bay. Secondary care is defined as institutional care (i.e. in-patient) with specialist consultations. Tertiary care involves more sophisticated technology and at a higher cost per patient. 54 frequently the private) health care system. In practice, however, these hospitals provide all care (including PHC) for their immediate catchment area. There are three Type A hospitals: Cornwall Regional Hospital in Montego Bay; the semi-autonomous University Hospital; and the Kingston Public Hospital. 4.7 Like health centers, there has been a decline in the number of hospitals functioning in the public sector and the total number of beds available. As part of a hospital rationalization program in 1985-86, the government converted five of the smaller Type C hospitals (with a total of approximately 400 beds) into the rural polyclinics referred to above. In the remaining hospitals, the number of beds has also declined, reflecting ward closings due mostly to staff shortages (Table 4.3). Even the University Hospital has as many as five wards closed because less than half of the nursing positions are currently filled. Table 4.3 Bed and average occupancy rates in public hospitals, 1988-1992 FACILITY TYPE 1988 1989 1990 1991 1992 TYPE A Bedcomplement 1268 1137 | 1102 | 1107i 1247 Average occupancy rate n. a. n. a. 85.7 82.5 70.7 Bed complement 760 | 620 | 726 | 736 740 Average occupancy rate n.a. n.a. 92.3 90.8 89.9 TYPE. C Bed complement 1062 | 951 ]0958 856 989 Average occupancy rate n.a. j n.a. 164.3 59.9 ] 59.1 Bed complement 2313 2319 2274 2274 2256 Average occupancy rate n.a. jn.a. 69.9 _ 63.5 j 62.6 T O T A_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Bed complement 5409 5021 5060 4973 ] 5231 Avege o. pancy rate 7,a, 8j ; ] 74.8 ] 69, Source: MOH, Health Information Unit, Hospital Monthly Summary Reports. 4.8 In 1988 there were 5,409 beds overall including the quasi-public University Hospital and the Bellevue Mental Hospital; by 1992, the number fell by just over 3 percent to 5,231 58. Type C hospitals had the largest drop from 1,062 beds in 1988 to 989 in 1992, or nearly 7 percent. Occupancy rates, on average, are also lowest for Type C hospitals (59 percent in 1992), followed by Type A (71 percent) and the Type B tend to have the highest average occupancy at 90 percent. For individual hospitals, especially Type C, occupancy rates are substantially lower (Annex II, Table 7). Over the period 1990 to 1992 occupancy rates for all hospital types has declined. 58 The three Type A hospitals have bed capacity between about 300 to about 550, while the Type B facilities range between 150 and 275; the number of beds in Type C hospitals are between 50 and 125. 55 4.9 Hospitals are organized into 10 hospital regions and administered by a Hospital Board appointed every two years by the Minister of Health (Annex II, Table 8).59 The management of the hospital is the responsibility of an Administrator, a Matron and a Senior Medical Officer with concurrence of the Regional Hospital Board. Budgets are conferred on a regional basis to the largest hospital which then administers the budget for other hospitals in the region. 4.10 Referral system. The public health care system offers the full range of primary through sophisticated tertiary care. Movement between the levels of the system and types of facilities is in theory governed by the referral system. Unfortunately, this system has not worked well due to lack of clear procedures for medical personnel for referral or admission--a characteristic of the highly dichotomized structure of the Jamaican health care system (i.e. primary vs. secondary/tertiary). Self- referral by patients to hospital outpatient facilities--when lower level facilities could handle the problem--is one reflection of this. In the years 1990 to 1992 over 80 percent of patients appearing in casualty departments of public hospitals were sell-referred. Self-referral is probably higher in tertiary facilities, such as Kingston Public Hospital which is the only public hospital in Kingston. An earlier study (Ross Institute Report, 1983) cited a figure of over 90 percent in the casualty departments of five general hospitals. While by nature casualty departments would receive some self-referred patients, figures of over 80 percent are high considering that even Type II health centers are intended to respond to simple emergencies. 4.11 Manpower. One of the major issues in Jamaica inhibiting the effective public sector delivery of health care is the supply of health manpower.60 Despite the high quality of training for most categories of health personnel, the public sector is unable to attract and retain sufficient numbers of trained and experienced manpower. Moreover, the demographic and epidemiological transition implies expanding needs for certain categories of health workers that are currently in short supply (e.g gerontologists). 4.12 In the Ministry of Health, the 1993 Establishment Act provided 10,323 posts. In addition, there are 993 posts for Bellevue Hospital and another 200 for the Governrnent Chemist and the Registrar General's Department. Of the 10,323 established MOH posts for 1993, there are approximately 2900 vacancies or 28 percent. The proportion of vacancies varies by type; Table 4.4 shows established posts and vacancy rates for selected cadre of health personnel. 4.13 Chronic shortages and high vacancy rates among key health personnel (notably nuises and pharmacists) have been a characteristic of the Jamaican public health system for the last decade. For Nurse level I, there was a 64 percent vacancy rate in early 1994. This shortage is more pronounced in public hospitals (where the rate was 67 percent) compared with health centers (only 48 percent). Approximately one-third of community or public health nurses working out of health centers were unfilled, while just over 40 percent of Specialist Nurse posts were vacant. Over a third of enrolled assistant nurse posts were also not filled. Forty-two percent of the midwife positions were also empty. Excluding University Hospital which is affiliated with the University of the West Indies (co-financed by other Caribbean countries) and the Bellevue Mental Hospital. 60 Other major inputs in the public health care system (i.e. drugs and equipment) will be discussed in the following chapter on health care financing. 56 Again, this phenomenon was more marked at hospitals were nearly half were vacant compared to health centers (37 percent). The majority of nurses leaving the service tend to be the most highly qualified. From January 1990 to September 1991, there were 318 terminations. Of these, 238 were classified as resignations and the remaining quarter were retirements. Three-quarters were registered nurses, another 11 percent were nurse midwives and the remaining quarter were enrolled assistant 61 nurses. 4.14 Among physicians, there is less of a vacancy problem. Of 569 posts for levels MDG I to VII, 490 or 86 percent are currently filled. Vacancy rates are higher at entry level positions (MDG-I) at 17 percent. However, these figures are somewhat misleading because the ministry currently employs 112 foreign physicians (or 23 percent of total filled posts), 30 in primary and 82 in secondary and tertiary. Under existing terms and conditions, the supply of Jamaican doctors has been inadequate to fill all established posts. Non-Jamaican doctors have helped to fill posts, especially in areas where they have been high vacancies. Vacancies tend to be concentrated in certain parishes and types of facilities. For example, rural communities served principally by health centers tend to have the greatest shortages of public physicians. And, one of the large Type A hospitals, Cornwall Regional Hospital, had a 39 percent vacancy rate for the physician cadre. 4.15 Severe shortages have occurred in other critical categories. According to the Director of Pharmaceutical Services MOH, 61 percent of pharmacist posts are unfilled. Of those that are filled, nearly a quarter are held by retired pharmacists. Pharmacy technicians are in full complement and in many instances underfill for pharmacist posts in dispensing drugs. This practice, however, raises serious concerns about safety; under Jamaican laws, pharmacy technicians are prohibited from dispensing without the supervision of a pharmacist. "Supervision" has frequently taken on a liberal meaning, in terms of geographic proximity of the supervising pharmacist. There are currently less than half of the cadre of medical technologists employed by the MOH. There is a similar shortage of health education officers who are responsible for health promotion in primary health care. There is less of a shortage of public health inspectors. Finally, the MOH currently employs only half of the technical staff (e.g. engineers) required in the area of building and equipment maintenance. 4.16 The availability of trained staff to deal with mental illness is also a concern. There are reports of a 70 percent vacancy level at Bellevue Hospital, the mental hospital. The Principal Medical Officer for Mental Health in the MOH is also vacant. If the figures in the disease burden profile for mental illness are even approximate, manpower shortages should signal an area for concern. 61 Levine, Ruth. 1992 62 Adam, S. 1993. 57 Table 4.4 Ministry of Health, selected established posts and staff in post, 1993/4 Manpower Category Established Filled Vacancy Posts 1993 1994 % Physician 569 490 14% MDG-VI + VII 5 4 20% MDG V 15 15 0% MDG IV 123 112 9% MDG III 87 81 7% MDG II 196 175 11% MDG I 143 118 17% Nurse, Community 222 147 34% Nurse I 1132 413 64% Hospital level 925 305 67% Health center level 207 108 48% Specialist Nurse 262 155 41% Hospital Nurse II 271 198 27% Nurse, Practitioner 76 56 26% Nurse, Anesthetist 31 24 31 % Midwives 629 265 42% Enrolled Assistant Nurse 1222 764 37% Community Health Aides 565 428 24% Pharmacists 153 60a 61% Pharmacy Technician 106 120 0% Health Education Officers 43 22 51% Public Health Inspector 440 353 20% Medical Technologists 168 80 52% Maintenance staff' 195 99 49% Sources: The Civil Service Establishment Orders, 1993; Ministry of the Public Service. a. Includes 14 retirees. b. Excludes support staff (e.g. secretaries, drivers). 4.17 It is difficult to interpret vacancy levels over time because reductions of established posts occurs on a somewhat ad hoc basis. Some reduction in positions may reflect facilities that have been closed, ironically originally due to staffing shortages. Nevertheless, compared to 1987 it appears that the vacancy problem has escalated among the nursing cadre, while diminishing for physicians; for nurses, vacancies were 23 percent, while 32 percent for physicians. The consequences of shortages of health manpower are, however, evident. Health centers and hospital wards have had to be closed. For those who remain in the service, there have been increasing occurrences of industrial disputes by health staff concerning the causes which have forced others to leave (i.e. poor remuneration and working conditions). 4.18 Causes underlying shortages. Among the factors influencing nurses as they choose to stay in the public health care system include: poor working conditions and most recently safety in the workplace; low salaries; inadequate housing facilities and or allowances, including transportation; and, lack of scholarships for advanced training, recognition and promotional opportunities. For nurses, options other than the public sector include the private doctors' offices, clinics or private hospitals. 58 Migration, however, is the most attractive alternative to public service with the U.S. or Canada being the most frequent destination. During the mid-1980s the in-migration of Jamaican nurses into the U.S. increased dramatically, from 8 in 1985 to 184 in 1988 and another 167 in 1989. This trend has likely continued because of recent U.S. nurse immigration legislation. The 1989 Immigration Nurse Relief Act identified nurses as belonging to a desirable or shortage occupation. In addition to favorable immigration regulations, the migration of nurses is facilitated by aggressive recruiting by foreign health care institutions. It is not uncommon for recruiters to pay for travel expenses for the nurse and her family, provide a cash to retire her bond to the government and provide housing subsidies while in the U.S. Current estimates of the differential between salaries paid to nurses in Miami versus Jamaica was roughly dollar (US) for dollar (Jamaican); depending on the exchange rate this represents an order of magnitude of some 20 to 30 times. 4.19 As will be discussed in the following section, opportunities for bridging the gap between public and private sector pay scales, doctors have decidedly more options not only by setting up private practice on the island, but even more desirable is to hold both a public post in a government hospital and a private practice. Regulations issued by the MOH in 1991 grant private practice rights to Medical Officers in the top two (out of five) MDG grades.63 These rights include admitting and caring for private patients on-site at the hospital either within (up to a maximum of 12 hours) or over and above a normal 40 hour workweek. Private practice is not to compromise or conflict with a doctor's responsibilities to his or her public patients, although there is a general feeling that in practice doctors are not available when scheduled for public patients, and private patients comprise the bulk of surgeries in some hospitals. In addition to opportunities provided to "public" physicians, the most valuable benefit in a typical compensation package is a duty concession on an imported vehicle, once every six years. Nurses do not have the same benefit, although they too work irregular and long shifts. 4.20 Compounding the high rates of movement out of employment in the public health system are low numbers of enrollments in public training programs. This despite the fact that nearly all training of health manpower is financed and undertaken at public institutions. In the 1980s there was a wide fluctuation in the number of graduates produced, especially in nursing categories. For example in 1979, 303 registered nurses graduated while in 1989 only 63 were produced. During the same period, the number of midwives trained dropped from 167 to 73. Despite pre-qualifying programs and no or nominal tuition fees, nursing schools in particular seem unable to attract students. Low compensation offered by the public service, lack of promotion within health careers, and the availability of other opportunities for students with good achievement at secondary institutions are among the reasons cited. Ironically, training personnel are also faced with high vacancy rates--nearly half of the nursing tutor posts for midwives were vacant. 4.21 Allocation of health manpower. There are some demand factors which contribute to manpower shortages in the public health sector. Shortages may be the result of MOH staffing configuration which are characterized by an overemphasize on relatively highly-trained personnel and low productivity. Analysis conducted by PAHO as an input into the design of the IDB HSRP Project noted that a portion of the manpower shortage could be eliminated by essentially turning the health manpower pyramid upside-down, reclassifying positions and changing the distribution of 63 In addition, Private Practice Guidelines have been prepared by Touch, Ross, Ogle & Co. for Kingston Public Hospital for introduction in 1993. 59 responsibilities. For example, the report recommended a 10 percent reduction in registered nursing categories, while increasing enrolled assistant nurses. This scheme would reduce the nursing shortage no more than 20 percent in IDB project hospitals. Another example of misallocation of staff is midwives. Despite the fact that over 80 percent of all deliveries now take place in hospitals, there are 50 percent more posts in health centers than in hospitals. And, as noted above, vacancies among hospital midwives are more pronounced than in health centers. Of those actually in post, it is not certain that their time is well spent. Unproductive time of health staff in health centers was found to be between 33 and 81 percent.64 Causes included excessive paper work, absenteeism, tardiness and poor transportation services and other necessary inputs. 4.22 Ironically, unfilled posts also hamper the MOH's Planning Unit. Half of the eight positions are vacant, including the Chief Health Planner and Manpower Development Officer. Redressing the inadequacies of health manpower will require a broad range of interventions, beginning with an adequate information base about not only vacancy levels but manpower needs based on utilization patterns. Merely increasing the numbers of health workers trained will not have the desired effect. For nurses, the government will be unable to meet U.S. salaries, nor match current private practitioners' income for physicians. A review of the salary structure is warranted however. Equally, if not more importantly, nurses listed poor working conditions as the most frequent reason for leaving the public nursing service. Lack of appropriate supplies with which to perform routine tasks contribute to low morale. Recent incidents involving the spillover of gang warfare into hospital wards have also created unease at the workplace. B. The Private Sector 4.23 The private sector provides a substantial amount of health care in Jamaica. Although previously a figure on the number of private doctors active in Jamaica was not known with any precision, recent estimates made by a study supported by an IDB project put the total number of doctors in Jamaica at approximately 1,200 (Table 4.5). Of these, there are an estimated 750 General Practitioners (GPs), 199 Medical Specialists, 197 Surgical Specialists and the Other remaining 55 are in fields such as Public Health, Epidemiology, Pharmacology, Microbiology etc. As noted above, drawing a distinction between public and private doctors is difficult. Although there are approximately 400 doctors in government service (including the University Hospital), most of the "public" doctors also have private practices, usually as a Specialist. Table 4.5 Number of physicians, by specialty, 1993 General Practice (GP) 750 Medical Specialists 199 Surgical Specialists 197 I Other Physicians' 55 Dentists 194 TOTAL 1395 Source: CIH, 1994 for total and private; Civil Service Establishment Posts filled for GOJ. 64 Desai, 1986. 60 a. Other include C/T surgery, cytology, endocrinology, epidemiology, microbiology, pharmacology, public health, sports medicine, virology. 4.24 The bulk of private care is provided on an out-patient or ambulatory basis, and accounts for over three-quarters of all outpatient visits. The number of private facilities reflects this, with more than 65 800 doctors' offices and private clinics islandwide . Many private GPs are located in rural areas and frequently are the only accessible doctor. Among physicians' surveyed, nearly one quarter of respondents reported having multiple practices (i.e. part-time practice in poorly served parish) to widen catchment population.66 (Annex 11, Table 9 shows a listing of specialties and parish). GPs probably see the bulk of patients. Unfortunately, there is not much detail about the composition of conditions seen by the private sector. A mapping study and physicians' survey concerning family planning services noted that the private sector had the highest number of service delivery points, including private doctors, pharmacies and hospitals. Among private providers, GPs figured prominently in rural areas, while specialists (OB/GYN) in urban areas such as Kingston comprised a high percentage of private outlets for family planning services. 4.25 A limited number of private practitioners--less than ten percent67--with admitting rights to public hospitals also provide inpatient care to their private patients. Other physicians wishing to admit a private patient to hospital have two options. The first is to send the patient to a public hospital through a casualty department and/or make a referral to a colleague with admitting privileges. This results not only in a loss of continuity of care, but also billable income. The second option is a private hospital, but this usually depends on whether the patient can afford paying private hospital charges either out of pocket or through insurance coverage. There are 7 private hospitals in Jamaica functioning as secondary facilities, five of which are located in Kingston. These hospitals treat an estimated five percent of all in-patients and have less than ten percent of the island's total bed capacity. They provide services that are equivalent to a Type B public hospital (i.e. not sophisticated operations or specialties that are available in the public tertiary institutions). A study in the late 1980s found that private hospitals were poorly run and only one operated at a profit. Private hospitals face rising health care costs and must pay for imported medical equipment and drugs out of their own revenues. They face similar competition (viz. U.S. and Canada) for nursing staff personnel. Fees charged by private hospitals are higher than in the public sector, but this reflects a better level of accommodations and hotel services provided. But, because the public sector nearly fully subsidizes inpatient care, cash flows of private hospitals suffer from a lack of paying patients. 4.26 Private pharmacies. Over the decade of the 1980s, the number of private pharmacies has grown. Today, there are 275 outlets registered with the MOH; this excludes drugs dispensed through private doctor's offices and clinics. Of those registered, about half are in the Kingston/St. Andrew/St. Catherine area and the remainder are mostly in urban areas. Private pharmacies are required to have a 65 RAND study. Bailey, W. and K. Hardy. 1994. 67 There are 85 established consultant posts in public hospitals and some 1200 doctors islandwide. 61 diploma level pharmacist dispensing drugs. There are an estimated 520 pharmacists with diplomas in the island.68 C. Utilization of Health Care 4.27 Given epidemiological profile and the characteristics of the public and private care providers, what kind and how much care do Jamaicans seek and where do they choose that care? The options range from free public clinics, public hospitals with nominal charges for those able to pay, relatively expensive ambulatory visits to private doctors' offices or clinics, and high cost private hospital care. The 1989 Survey of Living Conditions asked about utilization of health care in the month prior to the survey. 4.28 Curative care. Of the 14.5 percent of Jamaicans who reported an illness or injury in the one month prior to the 1989 SLC, half sought curative care, with an average of 1.3 to 1.7 visits depending on the age group. A higher proportion of women over the age of sixty reportedly sought curative care (58 percent), as did women in the childbearing age group 14-29 (54 percent). By income, the highest income quintile was more likely to seek curative care (nearly 60 percent) as compared to 46 percent in the lowest income group; the proportion of the remaining quintiles seeking curative care were in the range of 47-49 percent. The effect of education on adults seeking curative services was weak, yet mothers education was positively associated with a child being treated for treatment.69 4.29 Preventive care. Overall, sixteen percent of all adults and children sought preventive care, but rates varied markedly by age and gender (Figure 4.1). Almost 20 percent of children under 5 were reported to have sought preventive care (e.g. for immunizations), while only 6 percent of school age children received preventive care. For young males, preventive care remains about 6 percent until they turn 30, when the rates double to 12 percent. Nearly 20 percent of young women aged 14 to 29, however, sought preventive care, probably a function of childbearing. The rates for women in their 30s, 40s and 50s rises to 25 percent, while for men in the same age group the rate is about 14 percent. Use of preventive services peaked for both sexes over 60. 4.30 Income is a strong predictor for seeking preventive care. As income rises, so does the percentage of a quintile seeking preventive care. Nearly 23 percent of adults in the highest quintile sought preventive care, compared to only 13 percent of the poorest quintile and parent's income influences the probability of a child receiving preventive care. Own education levels have hardly any effect on adult use of preventive services (controlling for income). However, the 1989 SLC noted that mother's education is an important variable for children's use of preventive care. Thirty percent of their children whose mothers who had completed 9 years of schooling received some preventive care, while only 14 percent whose mothers had some primary education (6 years or less) got preventive care. 68 Director of Pharmaceutical Services, MOH. 69 Gertler, P. et al. 1993. 62 Figure 4.1 Rate of preventive visit by age and sex, SLC, 1989 45 40 r 35 30 25 . Females a20 U Males 1 5 101 5, 0-5 6-13 14-29 30-49 50-59 60+ age 4.31 Source of care. Data from the SLC and other studies estimate that by the early 1990s, over 60 percent of patients seeking curative care went to a private provider (Table 4.6). It is evident that the private health care sector expanded rapidly during the 1980s; earlier estimates from the mid-1980s estimated that the private health care sector provided only 30 to 40 percent of outpatient care. It is not unusual that some Jamaicans consult more than one provider. In the 1991 Survey, 7 percent sought care from both sectors, while the remaining ratio of private to public use was 58 to 35 percent, respectively. When disaggregated by age, children under one were slightly more likely to go to a public provider (56 percent), while adults were more inclined to seek private care. Persons living in urban centers outside the Kingston metropolitan area more frequently attended a private facility (69 percent compared to 58 percent), while just of half of those surveyed and living in rural areas visited a private provider. 63 Table 4.6 Source of curative care by patient characteristics, SLC, 1991 (percentage of persons seeking medical care) GROUP Source of Care Public Private Both Area Kingston Metro Area 35.8 57.8 6.4 Other towns 26.5 68.6 4.9 Rural 39.5 52.9 7.6 Sex Male 38.1 56.8 5.1 Female 34.0 58.0 8.0 Age (years) < one 55.6 33.3 11.1 1 - 4 43.2 52.7 4.1 5 - 13 29.8 67.2 3.0 14 - 39 34.7 57.9 7.4 40 - 59 29.2 59.7 11.1 60+ 34.5 59.1 6.4 JAMAICA 35.6 57.5 6.7 Source: SLC, 1991. 4.32 In terms of preventive care, 58 percent of adults went to a private provider. Of the remainder that went to a public facility, 75 percent of these visits were seen in health centers, and 25 percent in hospitals. Private doctors provided the overwhelming share of private visits by adults for preventive care. The exception is for women aged 14-29, where use shifts back towards the public sector, presumably related to antenatal and maternal services. For pre-school children, however, the pattern was dramatically reversed with 70-75 percent receiving care from public sources, usually clinics. Once children reached school age, the pattern switches again to private preventive services, especially for girls. Table 4.7 Source of curative care for adults, by income level, SLC, 1989 (percent) Income group Health Center Private Facility Public Hospital Other Poorest 19.2 57.6 22.2 1.0 2 30.6 48.2 21.2 0.0 3 14.8 65.1 18.8 1.0 4 9.1 60.8 25.8 4.0 5 7.2 74.0 16.8 2.0 Source: Gertler, et. al., 1993; from SLC, November, 1989. 4.33 Income levels have a pronounced effect seeking curative care from a private provider. As income levels rise, there is a strong switch away from public facilities, with nearly three-quarters of the top quintile preferring a private source (Table 4.7). Adults in the second poorest quintile reported the 64 lowest proportion seeking private care (48 percent), but nevertheless it is striking that even 58 percent of the poorest quintile sought care from a private facility. In terms of utilizing public hospitals, there is no discernible trend by income group. The 22 percent of the poorest quintile went to a public hospital while nearly 17 percent did likewise among the richest quintile; almost 26 percent of the fourth quintile followed suit. For preventive care, there is a similar strong income effect (Figure 4.2). The proportion of the highest quintile seeking preventive care from private facilities is almost double that reported by the lowest income group. For the poorest quintile, 40 percent sought preventive care through a private source, 44 percent from a public health center and another 14 percent from a public hospital. At the top of the income scale, 76 percent preferred a private provider, with only 12 percent seeking care from a public health clinic. Not unsurprisingly, the possession of health insurance increased the probability of attending a private clinic; 86 percent of those adults who sought preventive care and had health insurance went to a private facility. Figure 4.2 Rate of preventive visit for adults, by income group, 1989 100% 90% 80% 70% iOther 60% Pubhc Hospital 50%~ 40% L Health Center 30% _ Private 20% 10% 0% Lowest 2 3 4 5 Income group Source: SLC. 65 Table 4.8 Health care contacts, public institutions, 1983-1993 (in thousands) 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 Public Hospitals Discharges 148.8 147.2 133.0 128.9 134.3 134.1 126.2 138.7 133.4 134.7 130.2 Deliveries 45.1 41.9 40.0 38.5 40.2 41.6 42.6 43.0 43.4 44.4 45.9 Outpatient visits 582.2 551.8 446.9 420.6 450.4 436.5 401.1 399.9 386.4 411.0 357.6 Casualty visits 572.0 540.3 408.0 383.6 479.4 439.3 427.4 494.8 509.9 521.6 419.8 Sub-total 1348.1 1281.2 1027.9 971.6 1104.3 1051.5 997.3 1076.4 1073.1 1111.7 953.5 Health Centers Ante/post natal, 562.2 547.9 563.7 653.4 625.1 567.1 609.6 602.7 587.1 580.4 579.3 childhealth visits l l Curative visits 931.3 1139.8 1063.9 1039.6 1062.5 981.8 942.5 920.0 905.8 879.9 768.7 Home visits 372.5 462.9 302.5 233.7 246.6 212.9 229.6 228.0 318.6 325.6 334.4 Family Planning 227.9 294.7 366.7 344.6 344.8 302.5 299.3 281.2 289.3 266.4 198.8 visits I Sub-total 2093.9 2445.3 2296.8 2271.3 2279.0 2064.3 2081.0 2031.9 2100.8 2052.3 1881.2 TOTAL PUBLIC 3442.0 3726.5 3324.7 3342.9 3383.3 3115.8 3078.3 3108.3 3173.9 3164.0 2834.7 PRIVATE 1700.0 3100.0 8940.0 CONTACTS I I Il Source: Hospital Monthly Summary Reports, Monthly Clinic Summary Reports; private sector estimates for 1983 and 1988, Cumper (1990); for 1994, CIU (1993). 66 4.34 Trends in volume of care. Over the last decade, there has been a noticeable decline in the volume of care provided by the public sector, especially ambulatory curative services. And, although time series of the volume of care provided by the private sectors is not available over time, it is clear that there has been an increase in private provision. Table 4.8 shows health care contacts for public hospitals and health centers, by type of visit. In the decade since 1983, there has been a decline in contacts with the public health care system. By 1993, the overall number of contacts was 18 percent below 1983 levels; the drop was more pronounced, however, in public hospitals which had nearly 30 percent fewer patient contacts. Hospital outpatient visits fell off by nearly 40 percent. At health centers, the number of visits peaked in 1984, but by 1993 there were 23 percent fewer contacts71. The most pronounced decline at the health center level, however, is for curative services; the 1993 level was one third that in 1984. Detailed data on types of curative care sought reflect the disease burden profile earlier. After dressings, hypertension accounted for well over 10 percent of all visits (Table 4.9). Noticeable also is the increase in the number seeking treatment for sexually transmitted and pelvic inflammatory diseases, in part due to the expansion of STD clinics islandwide. STDs ranked third in 1992, followed by respiratory tract infections and diabetes. Table 4.9 Curative visits to public health centers, by selected diagnosis, 1989-1992 Diagnosis Number of visits (in '000) percent of total 1989 1990 1991 1992e 1989 1990 1991 1992 Dressings 226.2 229.0 218.6 224.4 22.2 22.0 21.0 22.3 -Hypertension 137.0 135.6 131.2 120.6 13.4 13.0 12.6 12.0 STDs 63.4 72.8 78.1 79.4 6.2 7.0 7.7 8.0 (incl PID) I _ Resp Tract 72.7 79.3 81.0 68.8 7.1 7.6 7.8 6.8 Infection I L l l Diabetes 52.0 53.4 51.2 48.9 5.1 5.0 5.0 4.9 Skin diseases 49.6 52.7 48.8 48.7 4.9 5.1 4.7 4.8 Trauma/injury 45.9 39.9 37.6 32.9 4.5 3.8 3.6 3.3 Source: MOH, Health Information and Epidemiology Units. e = estimated. 4.35 For private sector contacts, what limited trend data there are, point to an increasing use of private ambulatory care (Table 4.8). Estimates from the early 1980s put the number of private contacts at roughly 1.7 million; that figure almost doubled to 3.1 million by 1988. A calculation based on a limited survey of private physicians concerning the average number of patients seen per day and days 70 If only because of the fact that the volume of health care demand has been and will continue to increase due to more people living longer. 71 This decline may be slightly overestimated, because it is possible that due to changes in the way health center clinics offer various services, what would have required two visits to a center may be possible in one visit (e.g. immunizations combined with nutritional check-ups). 67 worked per year, generated a figure of 8.9 million, nearly tripling.72 Although two-thirds of both curative and preventive care is provided by private sector, there is little data concerning the specific conditions seen or type of services delivered at the outpatient level, except what can be surmised from the utilization data discussed in the previous section. And, despite the fact that the public sector has relative monopoly over inpatient facilities, quasi-public physicians utilize public hospitals in providing care to their private patients. Private hospitals offer only secondary services and account for less than 10 percent of all hospital discharges. 4.36 The present picture of the delivery of health care in Jamaica is a mixed system with increasing provision by private providers. For ambulatory care (preventive and curative services combined), the private sector is the leading provider, accounting for an estimated 75 percent of all visits in 1993.73 And, although the public sector facilities provided approximately 95 percent of the inpatient beds in 1993, (with private hospitals covering the remainder), there is substantial provision of private care in public hospitals. D. Determinants of demand 4.37 In order to better understand the drop in utilization of the public sector facilities--but especially in the case of ambulatory care--and the subsequent shift toward private care, it is necessary to consider the determinants of demand for health care. In general, the amount of health care demanded and the choice of provider is determined by a number of factors including: accessibility; the cost of care, both direct (fees) and indirect (waiting or traveling time); and the quality of care. 4.38 Access. Most Jamaicans have relatively easy access to all levels of the health care system, including the private sector. Ninety percent of all Jamaicans live within 10 miles of a primary health care facility. Based on information from the SLC, the median distance to reach a public health center is 1.5 miles and the average distance to a private doctor or clinic is 2.5 miles. A public hospital is 7 miles compared with 10 miles for a private hospital (Table 4.10). By regions, there is not much disparity, with the exception of private hospitals which are located in Kingston Metropolitan Area and in Montego Bay. Each parish has at least one public Type C district hospital, although all public hospitals are open to Jamaicans, including Type A and specialty hospitals which are concentrated in Kingston. 72 CIH, 1994. It should be noted that these three figures are not from a single tine series, rather they were estimated by separate authors. Nevertheless, they are probably valid for rough orders of magnitude. CIH, 1994. 74 University of the West Indies, 1989. 68 Table 4.10 Median distances to health facilities FACILITY TYPE Median distance Number Public health center 1.5 366 Private doctor's office or facility 2.5 c. 800 Public hospital 7.0 24 Private hospital 10.0 7 Source: Survey of Living Conditions, 1989-2, derived from Gertler et al., 1988. 4.39 Direct and indirect price of health care. Although government health services are either nominally free at health centers75 or have a small charge at hospitals, numerous studies and anecdotal evidence have indicated that in Jamaica, even the poorest groups are willing to pay for more expensive private care, if they choose to seek care. Indeed data from the SLC showed that not only does the poorest quintile use private care (see Table 4.7), but the mean cost (excluding drugs) was about 40 percent the amount paid by the top income group. The poorest group also spent about half as much for pharmaceuticals as did the top income group (Table 4.11). Despite higher private sector charges, prices in the private sector do not appear to be a deterrent. And, because there is not much difference in distance between public and private outpatient facilities, transportation costs and traveling time are also unlikely explanations in terms of preference for private care. However, anecdotal evidence strongly suggests that the greatest indirect cost to patients in many public facilities is waiting time, which is not surprising given staff shortages throughout the public system and in hospitals, the incentives for physicians to see private patients first and the lack of accountability for quality or patient convenience. Table 4.11 Mean expenditures for health care and drugs, SLC, 1992 (1992 J$) GROUP Mean total cost incurred for all visits Mean cost of drugs, by source in prior month, excluding drugs and insurance reimbursements Public Private Public Private QUINTILE l Poorest 11 96 24 150 2 7 152 13 155 3 7 130 20 155 4 14 175 12 285 5 26 235 20 325 AREA _ Kingston Met 22 T194 22 261 Area 22 194 22 261 Other towns 10 163 17 255 Preventive care and maternal and child health services are free, and there is a J$5 registration fee for curative services. User charges are discussed in more detail in the tollowing chapter. 69 Rural areas 11 | 155 15 | 213 Jamaica 14 167 17 234 Source: Survey of Living Conditions Report 1992, July 1994. E. Quality of health care 4.40 Quality of Primary Health Care Services. In trying to determine the reason for the shift to private providers for outpatient care, the quality of care is considered. A 1989 study of Primary Care 76 Health Facilities visited all public health centers and a sample of 189 private facilities. The survey identified eight elements that were considered important determinants of the quality of care. These included: physical structure; staffing; equipment; supplies (basic, deliveries and family planning); drugs; prenatal care (counseling and diagnosis); laboratory facilities; and related services. The results of the survey compared these elements for three sets of facilities: public health centers versus private; public urban versus rural health centers; public higher health centers (defined as Type III and above) versus basic (Types I & II) health centers. 4.41 Overall, public facilities provided better perinatal diagnosis and counseling, immunization and family planning than did private facilities. Public facilities, however, were in relatively poorer state of repair and were inadequately staffed regardless of type. On the other hand, private facilities were in better physical shape, had more equipment and supplies (with the exception of family planning commodities) and delivered laboratory test results more quickly than public clinics. With respect to antenatal care, the survey found that private clinics did not counsel pregnant women as fully as public clinics. 4.42 There were only a few disparities comparing rural and urban public facilities. Urban facilities were slightly better equipped for basic equipment, drugs and supplies than rural clinics. Comparing public Type I and II health centers with higher level centers, lower level facilities were in better repair and better staffed with midwives, which is not surprising given that midwives are the mainstay of personnel at those levels. However, basic facilities were noticeably low on drugs and supplies. Only 30 percent of basic clinics had a fifty percent stock of basic drugs on the day of the survey compared with 70 percent at higher level public facilities (Table 4.12). Overall, only about 40 percent of all types of public facilities had at least half the drugs in stock, with little difference between urban and rural centers. Just under half of private clinics had a similar amount of drugs available, although this indicator may be of less relevance since presumably most private patients would purchase drugs at a private pharmacy. In terms of basic supplies (syringes, needles, bandages and scissors), only 14 percent of basic facilities had at least a fifty percent stock of recommended items compared with over 40 percent for higher level clinics. It should be recalled that the top leading curative service sought at public health centers was for dressings! Private facilities were significantly better stocked; over 90 percent of facilities had at least half the number of recommended items. 76 Peabody, J. et al., 1993. 70 Table 4.12 Availability of selected drugs, by health center, 1990 (percent with at least 50 percent stock on day of survey) FACILITY TYPE Percent Public Urban 43.6 Rural 39.2 Basic Level (Type I & II) 30.0 Higher Level (Types III + above) 70.0 Private 47.8 Source: Peabody, et al. 1993. 4.43 The study concluded that unlike other developing countries, there were not significant disparities between urban and rural facilities and only modest differences between higher and basic health centers. Although health care resources seem to be fairly evenly distributed across public facilities, the study begs the question of whether the level of resources are adequate, inadequate or excessive. Manpower shortages are an obvious example of such inadequacy and in extreme cases, a reason for many of the closures of public health centers. Drug shortages are another reason that could well explain the shift away from public health centers toward private facilities. 4.44 Quality of care in public hospitals. Numerous studies have demonstrated that while hospitals account for the bulk of public health expenditures, their levels are underfinanced, resulting in not only reduced quantity of care, but also lower quality. The chronic underfinancing of maintenance costs over the last two decades has led to the deterioration of hospital physical structures and of equipment. Hospital operations and quality of care are affected by frequent equipment failures. A 1987 PAHO study found that X-ray services were functioning at only a quarter of Type C hospitals due to shortages of manpower and equipment failure. Such deficiencies are potentially life threatening. For example, operating theater equipment is not being sterilized properly, allowing for infection (including with the HIV virus). Other life saving equipment, such as ventilators, baby incubators and dialysis machines, are out of service due to lack of spare parts. And, the Health Facilities Maintenance Unit in the MOH is currently unable to calibrate or validate biomedical equipment, possibly rendering false diagnostic results77. As discussed earlier, shortages of health manpower in public hospitals is another critical variable which negatively affects quality of care, resulting in the closure of some wards (including wards for private patients). Waiting lists for elective surgery is another indication. 4.45 Despite the fact that private care costs more, the demand and willingness to pay for private services has been demonstrated across income groups. The relatively poorer quality of public health care services appears to be the major explanation for the noticeable shift from public to private sector for ambulatory curative care, even for the poorest groups. The willingness to pay for private health care indicates that health care consumers trade off nominally free public services for more costly but higher private quality care. HFMU, Recurrent Budget Summary for FY 1994/95. 71 F. Equity 4.46 Although from the supply side, it appears that there is an equitable distribution of public facilities, there are legitimate questions regarding the equity of access not only in terms of quantity of care, but also quality. The first issue concerns effective demand for hospital level services. There is a general feeling that in many public doctors violate agreements concerning the amount of time, attention and priority devoted to their private patients to the detriment of public patients who are unable to afford private fees. The extent to which public patients are crowded out in favor of private patients is not known for certain. Part of the difficulty in determining a measure of inequitable access is because private patients are frequently not identified as such for purposes of applying user charges (unless they are placed in private wards). Those unable to pay private consultants fees are likely to end up behind private patients on waiting lists, especially for surgical services. In a resource constrained environment with general shortages of staff and supplies, the abuse of private practice rights results in inequitable access. 4.47 Second, although the utilization data show that a significant proportion of the poorest groups in Jamaica are willing to pay for private care, this may not be a fair reflection of the affordability of the fee. Poor households may resort to borrowing, selling assets or foregoing food consumption to pay for medical care. The longer term effects on health and welfare of those that are most vulnerable may be significant. 4.48 Finally, while some caution should be used in interpreting the SLC question concerning the nature or gravity of a self-reported illness and subsequent utilization, the fact remains that half of Jamaicans who reportedly experienced an episode of illness, did not seek curative care. And, an even larger percentage do not seek preventive care. The third equity issue concerns those who truly cannot afford visits to private doctors' offices, nor can afford to wait all day in a health center (and then may not even be seen by medical personnel). It also raises questions of efficiency since when they eventually do need to access the public health care system, they probably enter at a progressed disease level requiring more medically sophisticated and technically intense treatment. Sicker indigent patients entering the system increases health care costs to the public health care system. 72 5. HEALTH CARE FINANCING A. Overview 5.1 Health care is financed through a variety of channels in Jamaica. Historically, the public sector has provided the majority of funds, although over the last decade an increasing portion is being financed by private sources. Out-of-pocket expenditures by individuals (user charges for public facilities, medicines, fees for private physicians and facilities) and private insurance have become the main source of financing health care in Jamaica. 5.2 Although a consistent set of time series for the share of private financing of health care is not available, several studies have estimated approximate shares. Cumper (1980) calculated total health care expenditures in 1980 to be J$235 million (in current prices) or roughly 5 percent of GNP. Of this, 60 percent was funded publicly, another 10 percent by the University Hospital of the West Indies (with a major contribution from the GOJ) and 30 percent by out-of-pocket expenditures. The Ross Institute Report (1985) estimated that in 1983 the public share had fallen to about 55 percent, with 45 percent coming from private sources. A 1994 analysis by the Center for International Health (CIH) 7 pieced together information from a variety of sources including private physicians and estimated that total health care spending in 1993/94 had increased to 8.9 percent of GDP, of which the public share was approximately 35 percent. The remainder came from private sources, a complete reversal of the estimated 1980 mix of financing. This increasing trend toward greater private financing of health care mirrors the marked increases in the private provision of care and a decline in utilization of certain types of publicly- provided health services. 5.3 Table 5.1 shows ambulatory and inpatient care by place of utilization as well as sources of financing. Private practitioners are the preferred provider of ambulatory care. Seventy-five percent of all ambulatory visits were seen by the private sector compared with 25 percent in public facilities. An even higher share of the financing came from private sources (out-of-pocket and insurance); public expenditures covered only 19 percent of the cost of ambulatory care. At the hospital level, the public sector "provides" 95 percent of all inpatient days in the sense that the beds are in public facilities. Private hospitals accommodated only 5 percent of all inpatient days. However, in terms of financing inpatient care, the private share is high--35 percent--because of costly payments made by private patients to their private doctors employed in public hospitals.79 A relatively small share of the private financing--certainly not more than 10 percent--could be classified as user fees paid directly to a public facility. The bulk of private financing of inpatient care accrue directly to private doctors. The 65 78 CIH (1994). "Jamaican Health Sector Expenditure-Based Analysis." Prepared for Milistry of Health through IDB HSRP Project, Boston University, 79 These figures have been calculated by the CIH based on assumptions concerning the number and cost of major procedures performed by specialists in both public and private hospital settings. This group has discussed the validity of these assumptions with both public officials in the MOH as well as knowledgeable private sector physicians. By their accounts, the assumptions appeared reasonable. 73 percent contribution of the public sector mostly finances operating costs of public hospitals, and provides an implicit subsidy to private providers who conduct their practice within public hospitals. One estimate of the public subsidy to private doctors operating out of public hospitals in 1993 was J$75 million or 7 percent of the MOH's net recurrent budget.80 Table 5.1 Public and private provision and financing of medical care, 1993/94 Type of Service: Public Private Share of | Share of Share of | Share of __________________ !Provision Financing Provision | Financing Ambulatorya 23% 18% l 77% 82% In-patient" 95% 47% 5_% 53% Pharmaceutical n.a. 35 % n.a. 65% Source: Center for International Health, 1994. Note: Financing figure refer to medical care and exclude administration, training, etc. a. Number of visits. b. In-patient days. n.a. Not available. 5.4 Estimates compiled by the CIH for 1993/94 cover total outlays for health care, including government (broadly defined to include Ministries of Health, plus health related services through the Ministries of Education, Labor and Welfare, and the Office of the Prime Minister), private out-of- pocket and insurance payments, as well as non-governmental organizations. Total estimated revenues and outlays for fiscal year 1993/94 amounted to J$9.1 billion (Table 5.2). This translates into approximately J$3,583 per capita (or US$105). Public per capita expenditures on health were J$1,249 (or US$37 in current prices). Overall, government financed about 35 percent of total health sector expenditures. By far, the largest source of financing were out-of-pocket expenditures which paid for just over half of all financial resources flows into health. Private insurance contributed 8 percent. NGOs (such as the Heart Foundation and the Diabetes Association) contributed 0.8 percent most of which went for health education messages and early screening services. In terms of total expenditures in the sector, 85 percent was for medical care, followed by 9 percent for administration (which includes an estimated amount for private hospitals and insurance). Expenses related to education and training of health personnel accounted for 2.4 percent, while public health outlays (defined as health education, environmental health and surveillance of communicable diseases) amounted to almost one percent. Maintenance of health facilities represented half of one percent, while Jamaicans spent 2.4 percent of every health dollar on the cost of obtaining medical care overseas. go CIH, 1994. 74 Table 5.2 Total health expenditures and rmancing, 1993/94 (in millions current J$ and percent) Source of $J percent Expenditure J$ percent Financing l MOH 2,817.7 30.9 Medical care 7703.0 84.5 Other GOJ 326.4 3.6 Administration 841.6 9.2 Insurance 756.8 8.3 Education/training 222.3 2.4 Out-of-pocket 4,916.8 53.9 Public Health 80.4 0.9 NGOs 73.9 0.8 Maintenance 43.2 0.5 Overseas 221.0 2.4 Overseas 222.0 2.4 TOTAL 9,112.6 100.0 TOTAL 9112.6 100.0 Source: Adapted from CIH, 1994. B. Public sector health expenditures 5.5 Central government. Figure 5.1 portrays the government's budgetary outlays since 1982/83 in constant 1988 Jamaican dollars. In 1984/85, central governrnent expenditures dropped by over 15 percent, recovered slightly from 1985-87 and expanded rapidly in 1988/89 in response to the ravages of Hurricane Gilbert. Between 1988/89 and 1992/93, the government's real budget fell by 23 percent, putting the 1992/93 budget on par with the level a decade earlier. This decline came mostly at the expense of the Figure 5.1 GOJ Real Expenditures, Recurrent and Capital, 1982-1993 (in billions real 1988 J$) 9 .-- -.. - 6 ~ v--I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 0 I 5 - - Capital - 4~~~ U Recurrent K - - -, i]~~~~~~~~~~~~~~~~~Total 0 , - - v 00 00 x 00 00 00 0 00 o 75 recurrent budget. The 1993/94 revised budget estimate provided a 20 percent real increase over 1992/93. Much of the increase was allocated to the recurrent portion to meet the unexpected rise in salaries which resulted from wage settlements for the security forces, nurses and teachers. The government's real budget, however, does not reflect actual resources available for investment or recurrent expenditures. Servicing the debt on both the capital and recurrent accounts has claimed between a third and almost a half of government budgets since 1982/83. The 1993/94 budget is no exception; total debt service was estimated to consume about 43 percent, leaving the remainder for expenditures of goods and services (Figure 5.2). Net of debt service, the level of real capital and recurrent expenditures for 1993/94 is about 5 percent below 1982/83. Figure 5.2 GOJ expenditures, with and without debt service, 1982-1993 (in billions 1988J$) 8 7 6 U Debt service 4 _ lil t' li Total excluding debt service 3 2 1 82/83 84/85 86/87 88/89 90/91 92/93 5.6 Ministry of Health. Against this constrained fiscal backdrop, the share of public resources allocated to the health sector is shown in Figure 5.3. Between 1982/83 and 1986/87, the share of health expenditures fell from 7.9 percent to 5.5 percent of the total government budget (including debt service). This share increased in the period 1987/88 to 1990/91, rising to 7.5 percent. The recently revised 1993/94 budget included substantial salary increases for nurses and thus brought the MOH's budget back to its 1991/92 level. Net of debt service, the sector has commanded between 10 and 14 percent of the resources available for expenditure. Over the last five years, capital expenditures for health have significantly increased as a share of the total available capital budget (Figure 5.4). In the 1980s, capital outlays for health were no more than 2.5 percent of total government capital expendi- tures net of debt service. By 1990/91, the MOH was allocated over 6 percent of the total capital budget and in the last two budget cycles that figure rose to 12 percent. Recurrent expenditures held a 76 fairly constant share of government's recurrent budget (averaging about 8.5 percent including debt or about 15 percent excluding debt service), albeit of an undulating level of real total recurrent resources. Figure 5.3 Total MOH expenditure as share of GOJ, 1982-1993 (percent) 16 14 12 10 8 6 |4|1 Toal Ait dbl sec 6. | l lt | { I |- | 4| I K i * Total W/o dxszvice 2 0* n tt V) C) tO - Y 0 t _ F 00 Y Y0 x0 x a e o x bi (D r- tnxt : 00 00 00 Y 00 00 X Y O Figure 5.4 MOH capital expenditures as share of GOJ capital, 1982-1993 (percent) 93/94 _______=________ 92/93 . . 91/92r . 90/91 = === = __ _ 1 89/90 88/89 Capital w/o debt service 87/88 _ 0 Capital with debt service 86/87 85/86 84/85 83/84 82/83 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 percent 77 5.7 Although in nominal terms, aggregate levels of expenditure for health have consistently risen over the last decade, real expenditures followed a similar pattern as aggregate government outlays (Figure 5.5). Between 1982/83 and 1986/87, real resources allocated to the health sector declined by roughly one third, despite the recent expansion of the primary care network during the late 1970s and into the early 1980s. Recurrent expenditures bore the brunt of these cuts and threw the sector into a financial crisis. The Ministry of Health responded in 1984 by raising user fees to more realistic levels (they had not been adjusted since their introduction in mid-1960s). The ministry also converted some Type C hospitals into large health centers. And, in 1984/85, there was a drastic cutback in temporary staff, including a 50 percent reduction in the 1,200 Community Health Workers that were an important element of the delivery strategy for primary care. At the same time, discussions began about divesting non-medical support functions of large public hospitals. It was not until 1987/88 that public health expenditures rose again, with Hurricane Gilbert no doubt taking some of the credit, but the establishment of the HRDP probably was a contributing factor in restoring resource levels. Beginning in 1990/91, however, there followed two more years of sharply declining real budget allocations for health. Again, recurrent expenditures took the hardest hit. The decline was arrested in the 1993/94 budget with a 30 percent real increase, but that was due primarily to salary increases arising out of industrial disputes between nurses and the government. While the recurrent budget mirrored the ups and downs of the total MOH budget, it is noticeable that the capital budget has steadily increased its share from 5.3 percent of total MOH expenditures in 1987/88 to just over 20 percent in 1993/94-- nearly a four-fold increase. Projections are that the capital budget will to rise over the next several budget cycles as major civil works under the IDB's Hospital Restoration Project are implemented. Figure 5.5 Real MOH expenditures, capital and recurrent, 1982-1993 (in millions 1988 J$) 600 500 400 U iCaptl 1 300 URecurrent Total 200 100 r'4 i ~ r- w 0< O _ x0 x0 00 X0 Y 05 .0 00 0' 0' 0' 0' 78 5.8 Capital budget. The late 1970s and the first half of the 1980s saw major investments in health center infrastructure as the primary care network expanded. Investment for secondary and tertiary hospital care was, for the most part, low during this time. Since 1988/89, allocations to secondary and tertiary care not only increased as a proportion of the total capital budget, but significantly increased in real terms as the capital budget expanded. (Figure 5.6). The capital budget is presented in two accounts: the Capital A budget is funded solely with GOJ resources, while the Capital B budget is primarily financed with external resources with GOJ counterpart funds. Since 1982/83 the Capital A budget has shrunk as a proportion of the total capital budget, from nearly 60 percent to about 12 percent in 1993/94 (Figure 5.7). It is interesting to note that the major proportion of the Capital A budget during the 1980s and, somewhat less so in the 1990s, has consistently financed secondary and tertiary care (Figure 5.8). Up until the late 1980s, the capital budget financed by external sources was entirely expended for primary health care (Figure 5.9). he coming on stream of the IDB's HSRP project is clearly reflected by the 1988/89 budget cycle. By the projected 1994/95 budget year, expenditures for secondary and tertiary care will consume over 90 percent of the total capital budget for health. Figure 5.6 Real MOH capital expenditures, by major program, 1982-1993 (thousands 1988 J$) 140,000 120,000-1 100,000- _ Family Planning 80,000 U Social & Econ Support * Training 60,000- O Health Services Support * Pharmaceutical Service 40000- 0* Primary Health Care 20,0010 _U_ * Second & Tertiary Care 0 00 00 00 00 00 00 00 oo C- .1 ir ~ c r- oc CN 0000 00 00 00 00 00 00 d\ N O ON 79 Figure 5.7 Relative share of MOH capital A and B budgets, 1982-1993 100% - 90% 70% k 60% 50% |I -Capa* il 40% 1] Capital A 30% r 20%~ 10%l ' 1, L 1 7 00~ 00 00? 0 00 00 00 ~ o Ce1 m Lx d' . '~ t .10 r- 00 ON. Q - r 00 00 00 00 00 00 00 00 ' 0. 0. Figure 5.8 MOH Capital A expenditures, by major program, 1982-1993 1qIff ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ mammsf °~~~~~~~~~~~~~ aui&lbt~iycr 4''' 983 (YJ85 N6 H7 8718 DSO9091 91/yH Bhar 80 5.9 Recurrent budget--allocations by level of care. Figure 5.10 shows the allocation of recurrent expenditures. Over the last decade, secondary and tertiary care has consistently absorbed between 60 to 70 percent of total recurrent budget of the Ministry, while primary care has vacillated around 20 percent.81 At the hospital level, the three tertiary care facilities absorbed 38 percent of the recurrent budget in 1992/93. Nearly half of this, the Government of Jamaica provided to the University Hospital, associated with the regional University of the West Indies. MOH support comprises approximately 70 percent of the University hospital's recurrent budget. Hospitals providing secondary referral (or Type B hospitals) received about 17 percent of recurrent outlays, while the district hospitals (or Type C) secured about 13 percent. Expenditures for central administration also stayed roughly constant as a share of recurrent budget (at less than 10 percent). The sharp rise in administration's share for 1993/94 is due to the salary settlements for selected health care personnel.82 Health services support includes recurrent expenditures for laboratory and diagnostic facilities, as well as central level support for a health facilities maintenance unit. Figure 5.9 MOH Capital B expenditures, by major program, 1982-1993 90% 80% 70% Training 60% I 1 Pharnaceutical Service .0% I I [ Family Planning 40% j * Health Services Support 30% * Primary Health Care -20% | _ * Second & Tertiary Care 10% 1_ _ _ 0% _ __, 0 a) Lo c o aw OD a o en - * LO (D r- 0 n 0 o N co (D OD 00 en c:2 co 0 a a) a) 0 The share of expenditures for primary care is probably slightly underestimated because the data are allocations by level of facility and not by type of care actually delivered. Due to the malfunctioning of the referral system and the relatively poorer quality of care available at many health centers, many primary health care services are being provided at the hospital level in casualty or outpatient departments. s2 Note that payments based on agreed awards with major personnel groups were in fact not made in FY93/94. Therefore, the 93/94 actual expenditures will be revised downwards and reallocated into the 94/95 budget. 81 Figure 5.10 Allocations of MOH recurrent budget, by major program, 1982-1993 100% 80% TRAINING 70 HEALTH SERVICES SUP 60% ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~IPHARMACEUTICAL Serv 30% ijEXEC DIR/ADMIN 40 31 SEoCONDAtRYS: g 20% 30% 0%- 5.10 The fluctuation in the real recurrent budget has been clearly absorbed by the share for secondary and tertiary care (Figure 5. 11), leading to the rapid deterioration of the physical and equipment stock of the hospital system and to insufficient operating budgets. And, despite the expansion of the primary care infrastructure in the late 1970s and early 1980s, its recurrent budget remained constant in real terms, albeit protected from a vacillating total recurrent budget Figure 5.11 Real MOH recurrent expenditures, by major program, 1982-1994 (in millions 1988 J$) 450- 400- 350- 3004- 250- El HEALTH SERVICES SUP 200 - ]PRIMARY U5 l SECONDARY i50- . 82 5.11 Recurrent budget--allocations by expenditure category. Compensation (i.e. wages and salaries) along with subsistence and travel allowances account for the bulk of the Ministry's recurrent budget (Table 5.3). Over the last three budgets, outlays on personnel have increased from 61 percent to 79 percent in the 1993/94 budget. The phenomenal increase in the last budget was due to negotiated wage settlements with nurses and other health personnel. The next largest category of expenditure is "purchases of other goods and services" which includes drugs and medical supplies, and maintenance. Overall the share of other goods and services has steadily fallen from 28 percent in 1991/92 to 17 percent in 1993/94. Within the goods and services category, budget allocations for the purchase of pharmaceuticals has also fallen from roughly 12 percent to just over 6 percent in the same time period. The budget for maintenance was 4.3 percent of the budget in 1992/93 and fell to 3.2 percent in 1993/94. During the real recurrent budget contraction between 1991/92 and 1992/93, compensation actually increased its share of the total (and real) value, while the cut was disproportionately felt in the purchases of other goods and services (i.e. drugs and maintenance). 5.12 Personnel. Despite the fact that personal emoluments and wages continue to receive the largest share of the budget, in general salary levels in the public service have tended to be adjusted more slowly than cost of living indices. The effect has contributed to high vacancy rates and the difficulty experienced by the MOH in recruiting and retaining health personnel, especially nurses. 5.13 Pharmaceuticals. Funds for pharmaceutical services included under the MOH's recurrent budget rose sharply in 1988/89 from 4 percent of recurrent budget to nearly 12 percent the following year, with similar levels through 1991/92 budget year. In 1992/93 purchases of drugs from the recurrent budget fell to about 8 percent of the recurrent budget. And, in real terms expenditures for drugs fell by 40 percent between 1991/92 and 1992/93, further exacerbated by the sharp devaluation of the Jamaican dollar in 1991 (1991/92 J$ depreciated by 60.9% increasing the cost of imported goods). Pharmaceuticals increased in real terms by about 20 percent in the 1993/94 budget, however the effects of a second major devaluation by about 30 percent in 1993/94 further eroded the purchasing power. In the 1993/94 fiscal year, government outlays for drugs was estimated at about J$190 million. Table 5.3 Composition of recurrent budget, by type of expenditure, 1991-1993 (percent) ITEM 1991/92 1992/93 1993/94 Compensation,subsistence/ travel 60.9 68.6 78.7 Net purchase goods/services 28.0 23.9 16.7 - Pharmaceuticals 12.1 X= 8.2 6.4 * Maintenance 3.1 3.6 2.2 * Other 12.8 12.2 8.1 Public utility charges 7.9 5.3 3.1 Net grants and contributionsa 1.7 1.1 0.7 Property rental _ _1.3 _ 0.9_ _ 0.6 Equipment purchases _0.3 0.2 0 .1 Source: MOF, Budget Estimates, various years. a. Excludes transfers to University Hospital and the National Family Planning Board which are classified as "grant and contribution". It is assumed that they have a similar distribution of expenditures. 83 5.14 Maintenance (Equipment and buildings). Maintenance budgets for both physical infrastruc- ture and equipment (both medical and non-medical) have been chronically underfunded for years in Jamaica. The deferring of routine and preventive maintenance in favor of other expenditures as a short-term solution when faced with tight budget constraints has unfortunately become a long-term practice. A decade ago (Ross Institute Report), funds for maintenance were limited compared with recommended levels. Based on World Health Organization guidelines, approximately 10 percent of equipment value and 2 percent of facilities' value is needed annually for preventive and routine maintenance. In Jamaica, it has been estimated that the health sector's capital stock (buildings and equipment) is about J$6 billion implying that roughly J$600 million annually would be required for maintenance. In fact, the recurrent maintenance budget for 1993/94 was J$42 million or about 2.2 percent of the MOH recurrent budget. An additional J$51 million was allocated in the 1993/94 Capital A budget. 5.15 Over the years, the deferral of routine maintenance of health facilities and medical equipment in favor of meeting payroll expenses in an environment of falling real recurrent budgets has contributed to the deterioration of the capital stock, especially at the secondary and tertiary level. When this practice results in acute problems, costly rehabilitation projects are needed to correct them. Indeed, the IDB HSRP project and the refurbishing of health centers under the World Bank's Social Sector Development Project and the Population and Health Project are good examples of effectively shifting recurrent expenditures to the capital budget. And, in the case that this involves loan funds, it also contributes to the debt burden and future foreign exchange requirements. The implications for sustainability of investments undertaken today (themselves corrective action for deficient recurrent expenditures) are evident. Planned preventive maintenance is clearly cost-effective in the long run. 5.16 Hospital sub-sector: expenditures by major disease categories. In terms of the distribution of hospital costs across major categories of conditions, rough estimates from 1985 indicated that the largest share was for chronic and non-communicable diseases (44 percent). Moreover, this share was larger than at first indicated by the proportion of total admissions, implying that chronic conditions are also more expensive to treat.83 As the demographic and epidemiological transition proceeds, it can be expected that the demand on hospital services for treatment of chronic care will become increasingly expensive. Unfortunately, although computer budgeting systems are beginning to be installed in major hospitals, there is a paucity of cost data such as the unit cost of a given health intervention (e.g. a normal hospital delivery or an appendectomy) or treating an episode of a specific health condition (e.g. tuberculosis). 5.17 Road traffic accidents are not only a substantial source of both mortality and morbidity in Jamaica, but they consume substantial resources. A study that examined 200 random admissions to Kingston Public Hospital due to road accidents found that nearly one third sustained severe injuries.84 83 Pregnancy and perinatal conditions followed second at 23 percent. Source: Preparation documents by PAHO for the HSRP Project; the percentage of distribution of admissions were first multiplied by the appropriate case mix weight; see Barnum and Kutzin, 1993, page 46. Simmonds, 1993. 84 Of those admitted to hospital, the mean length of stay was 32 days, with an average of 5 medical interventions per person with an associated mean cost of J$29,105 (in 1992 J$). The average cost for a patient seen in casualty was J$372 with 2.4 medical interventions on average. Excluding follow-up care and rehabilitation, the study estimated that in 1992 total costs of treating traffic accident victims would be approximately J$35.7 million. C. Private expenditures 5.18 Private financing of health care is significant in Jamaica--providing two out of three dollars flowing into the health sector. Private expenditures are predominantly direct out-of-pocket payments for: i) user charges in public facilities (especially hospitals); (ii) private doctors' fees or private hospital charges; and (iii) pharmaceuticals from private outlets. In addition, employers, employees and/or individuals may make payments to insurance companies for health coverage, which in turn pay out claims for health services consumed. On average, 2 percent of total consumption per capita went for health care, according to the 1992 SLC. For the poorest quintile, this amounted to 1.6 percent of per capita consumption, rising steadily to the top income group who spent 2.2 percent on health care. 5.19 Userfees in publicfacilities. User charges have been in effect in public hospitals since their introduction under The Public Hospitals Act and Hospital Fees Regulations of 1968. In addition to a range of fees for different hospital services, there is a nominal charge for curative visits to health centers. Preventive and maternal and child health services are free at health centers. In order to ensure that those unable to pay still have access to needed services, several categories of exemptions apply. Any person receiving food stamps under the government's Food Stamp Program is exempt (e.g. pregnant and lactating women, children under five, and the indigent). In addition, dental treatment for school children is also exempt. Finally, it is Ministry policy that no one is turned away if they do not have sufficient cash with them to pay, although they may be billed for services later. 5.20 User fees support two broad policy objectives in Jamaica. The first is to increase beneficiary cost sharing and generate additional revenues. The second is to improve efficiency by embedding utilization incentives in the pricing structure. With regard to revenue generation, actual revenues collected through user charges have not been substantial. In the early 1980s, fees were less than one percent of major hospitals' operating budgets. Then, in 1985/86 hospitals were permitted to retain at least 50 percent of fees collected, provided they submitted a proposal to MOH for how the funds would be spent. The remaining half could also be accessed from MOH. It should be noted that these funds are not incremental to approved recurrent budgets, they are considered appropriations-in-aid to both the MOH and the collecting facility. The advantage, however, is that the hospital has immediate access to the funds, for which they must otherwise wait for quarterly releases from the MOF through the MOH. Since hospitals were permitted to retain some portion of fees, fee collection has improved. By 85 1986/87, hospitals were collecting just over 3 percent of their operating budgets. By 1992/93, user fees averaged about 4 percent or J$20 million. After the introduction of a new fee schedule in 1993, revenues reached J$51 million or an average of 6 percent. For that year the MOH set an overall target 85 Kutzin, J. (1989). "Analysis of Jamaica's Public Hospital User Fee System," Supplementary Analysis B. 85 of 8 percent, with individual hospital targets ranging from 5 to 13 percent. Although on average hospitals failed to reach that target, 6 out of 20 hospitals surpassed their targets. 5.21 There are a number of factors that undermine the policy's impact on revenue generation. First, the fee structure is not automatically indexed for inflation. The first price adjustment was done in 1984--some 16 years after their introduction.86 The second fee adjustment was only made in 1993 with eight years of high inflation in the interim. Moreover, what little was collected probably did not offset administrative costs borne by the MOH. Second, the differentiation between hospital charges for public and so-called "private" and/or insured patients is modest. As noted earlier, private patients typically have preferential access to the top of waiting lists, better rooms and command the immediate attention of the doctors they pay on a private basis (despite the fact that these same doctors are also public civil servants). The third factor contributing to low revenue generation is a combination of poor collection of fees from those who should pay and the high number of exemptions. Although 30-40 percent of the population could be officially exempted, data from the 1989 SLC indicated that fees 60 percent reported paying nothing. A rough calculation in 1986 found that only about 20 percent of potential revenues were collected. A recent study87 estimated that doubling collection of outpatient hospital fees (i.e. reducing those who pay nothing to 30 percent) would raise revenues by 75 percent, while doubling the level of fees (with 60 percent still paying nothing) exempt would increase revenues by only a third. 5.22 The second function of user fees is to enhance efficiency by reducing unnecessary use of health services and increasing the rational use of facilities.88 The present fee structure does not effectively support this objective. Public patients without health insurance are charged a single admission fee for medical treatment and accommodation, instead of a daily rate. And, drug charges for all patients are per prescription and not per item. This flat fee structure has the effect of encouraging longer stays and over prescription of drugs. Hospital fees are also uniform by level of hospital so there is not an incentive for patients to use lower level hospitals even though they would be adequate to deal with most health problems. This practice perpetuates the current imbalance of crowded Type A tertiary hospitals and the under-occupied Type C district hospitals. 5.23 Efforts are currently underway in hospitals to train staff to improve collection of fees. Interventions include hiring supplementary staff, improved cash handling practices to reduce losses from theft, and training in methods to assess patients' ability to pay. The MOH has also initiated a social marketing campaign entitled "Share Care" to communicate to hospital staff and patients the need for user fees and the relationship between increased fees and improved quality. S6 Although a present MOH proposal does contain a provision to index the fees to inflation. 87 Gertler, P. (1993) "User Fee Policy Simulations from a Provider Choice Model." 88 Lewis (1988) found no change in the number of patients after the incease in fees in 1984, perhaps because even then the cost were still very low. The later decline in utilization of public facilities was unlikely due to user charges; there was no change in the fee structure from 1984 to 1993. 86 5.24 A proposal to the Ministry of Health89 suggested ways in which the fees could be structured to eventually generate 32 percent of costs of an average medical admission to hospital and at the same time, allow for substantial cross subsidization, not only across types of patients (public, private, indigent), but also with shorter hospital stays subsidizing longer stays (Table 5.4). The proposal also suggest that fees be differentiated by level of hospital. Consideration is also being given to the introduction of more substantial fees at health centers.90 Although there are strong arguments for continued full government subsidy for preventive and MCH services, there may be similar grounds for some subsidy which encourages preventive care or early treatment of chronic conditions with cost effective drugs at health centers. 5.25 Any consideration of raising the level user fees in public health facilities (over and above adjusting them for inflation) must take into account the equity implications. Data on price elasticity of demand (what happens to demand of a good when its price is raised) can shed light on the potential impact of changes in user fees and send signals when price levels might inhibit the poor from seeking care. Based on data from the 1989 SLC, Gertler et al. (1993) suggest that the demand for public health care is price-inelastic and that fee increases will not substantially reduce utilization.9' However, the data also show that the poorest quintile are about one-third more price sensitive than individuals in the richest quintile. Any proposal to increase fees, particularly at facilities utilized most heavily by the lowest quintile--i.e. health centers--must carefully consider the revenue-equity tradeoff. Table 5.4 Proposal for cross-subsidization of user charges Public patient Private patient Indigent INPATIENTS l Percent of 55% 25% 20% inpatient l Percent of fees 35% 65% 0% generated OUTPATIENT Percent of 75% 15% 10% outpatients Percent of fees 62% 32% 0% generated Source: Shepard, 1994. 5.26 Simulations by Gertler (1993) using the SLC data also suggest that while the demand for public care is price inelastic--and that for hospital outpatient more so than health center visits--private care is 89 Shepard, D. (1993). 90 Shepard, D. (1994). 91 In other works, a one-percet rise in the fee will lead to a less than one-percent increase in the number of people the fee deters from seeking care. 87 price elastic. A one percent increase in private charges would generate a 2.6 percent decline in utilization. Users of private care are apparently willing to switch to other providers or to forgo medical care if faced with such an increase. This effect is more pronounced for lower income groups (3.2 percent) compared with the highest group (2.3 percent). These simulations also support the earlier assertion that quality and not price is a major determinant of demand for health care. Charges in public sector facilities did not change in the ten years 1984-1993, yet there were substantial declines in utilization. 5.27 Fees for service--private sector. The bulk of private financing of health care are direct fees for service paid to private providers. In 1993, this amounted to roughly J$6 billion--or almost double total government outlays.92 Of this, about three-quarters was for ambulatory care (i.e. services delivered in a private doctor's office or clinic); the remaining quarter was for in-patient services. Average fees for GP office visit have increased in nominal terms over the last decade, but they do not appear to have outpaced inflation.93 In 1993, an average charge for a visit to a GP would be J$230. An office consultation with specialists cost significantly more: a medical specialist would cost J$469, and that for a surgical specialist would be J$441 . Although private patients are required to pay fees in public hospitals, they also pay a private fee directly to the physician for his/her inpatient services. The average private fee for a major procedure would be almost J$18,000 (excluding hospital charges), while a minor procedure would cost J$2,900. 5.28 Physicians in private practice in 1983 were estimated to have received 60 percent of their income from fees, 25 to 30 percent from third party insurance reimbursements, 5 to 8 percent from employer-provided negotiations, and 3 to 5 percent from capitation (e.g. old peoples' homes, schools). The CIH study undertook to estimate average gross revenues for broad categories of private doctors, based on an average number of visits per day, procedures per week and days worked per year. They found that for an average GP, gross annual revenue was estimated to be J$2.2 million (or about US$65,000 in 1993 prices). For a Medical Specialist, gross revenues were estimated at J$3.3 million (US$96,000) and for a Surgical Specialist (working an average of 168 days per year), average gross revenues were over J$5 million (or US$154,000). Out of gross revenues would come income tax and operating costs for a private office and any staff. However, the "public" specialist physician with a private practice in a hospital setting, is not charged any fee by the hospital for use of hospital space, operating facilities, laboratory or diagnostic services, staff or supplies. It is interesting to note that the current top salary figure (including all benefits) offered for the most senior medical post (MD-V) in a public hospital is J$246,970. If this physician happened to be the average Surgical Specialist (not unlikely), his government salary would represent only 5 percent of the gross annual private practice revenues. In other words, it would take just over two weeks in private practice to earn his annual GOJ 92 CIH (1994). From various data sources: In nominal terms, 1981--J$20; 1988--J$60; 1990--$J100; and 1993--J$230. In 1988 J$, these would roughly be equivalent to: J$45; J$60: J$73; J$50, indicating that in the last three years, prices have fallen in real terms. CIH, op. cit. 88 salary. Most private physicians probably do not hold government hospital posts for the salaries offered, but for the admitting privileges, a necessary input for conducting major surgery in private practice. 5.29 Pharmaceuticals. About 15 percent of private expenditures for medical care was to purchase pharmaceuticals. This amount also comprised 70 percent of all drug expenditures in Jamaica, with the remainder financed by GOJ. Private pharmacies have expanded in parallel to the growth of private providers of health care. In addition, they have also responded to meet demand when drugs prescribed in public sector facilities are out of stock. Until recently, drugs for the private sector were imported through the government parastatal, the Jamaican Commodity Trading Corporation (JCTC). JCTC charged the private sector an 8 percent fee for procuring generic drugs and a 4 percent fee for brand name drugs since the base price for latter was much higher. This, however, undermined the government's policy to encourage the use of generic drugs instead of brand name drugs (when appropriate). JCTC no longer procures drugs for the private sector. There were also price controls imposed on the private pharmaceutical sector. In the early 1990s, drug prices in the private sector were liberalized at both the wholesale and retail levels. Drug prices rose dramatically and for selected basic drugs, there is a substantial price differential between private pharmacy and health center (Table 5.5). Table 5.5 Price variations for a sample of drugs, 1994 (used for chronic conditions) DRUG USE Difference Government & Difference Brand & Generic Retail Price Retail Price Piroxicam Arthritis 939% 518% Atenolol Hypertension 793% 35% Salbutamol inhaler Asthma 347% 84% Becotide inhaler Asthma 123% No generic Timolol maleate Glucoma 185% 49% Insulin Diabetes 108% 42% Carbamazepine Epilepsy 177% 212% Source: MOH Budget presentation, Hon. Minister D. Leakey, June 1, 1994. D. Insurance industry 5.30 The health insurance industry in Jamaica as it presently exists was created in the 1980s. It is mostly private95 and there are five main carriers of health insurance, four of which are life insurance companies offering health packages; only one (Blue Cross) deals solely with health insurance. 5.31 Group health insurance plans comprise the bulk of private insurance.96 In the early 1980s between 6-7 percent of the population was covered. By the mid-1980s estimates ranged between 10 There is some health insurance provided under the National Insurance Scheme administered by the Ministry of Labour and Welfare in order to cover worker's compensation in the event of occupational injuries. 89 and 12 percent. Although some 15 percent of the total population is insured presently, a recent islandwide survey found that about 40 percent of the working population was covered by some form of insurance.97 This figure rises to 51 percent in the Kingston Metropolitan area, while rates are lower outside the capitol area (36 percent). The proportion of those with health insurance rises steadily as income rises. Among the poorest quintile, 1.6 percent had coverage in 1990, while nearly 19 percent of the richest quintile reported having some form of health insurance. 5.32 Total claims during 1993/94 amounted to just over J$500 million and accounted for an estimated 6 percent of total public and private expenditures for medical care (i.e. excludes administra- tion, training etc.). Of private outlays for medical care, private insurance covered about 8.5 percent, implying that 90 percent of private expenditures on health are out of pocket.98 It should be pointed out that although insurance is thought of as private expenditure, the largest employer in Jamaica offering health insurance benefits is the Government which purchases coverage through Blue Cross. An estimate of the total expenditure by the Government for private health insurance is not easily determined because premia are included in the salary items for each ministry's budget. 5.33 Over 70 percent of claims submitted are for the costs of ambulatory services (doctor's fees) and purchases of drugs (Table 5.6). Since 1986, the share for drugs has increased (from 34 to 42 percent in 1992)99 reflecting inflation and the exchange rate impact on drugs prices. Between 1986 and 1992, reimbursements for physicians has dropped from 47 to 30 percent. In 1986, 13 percent of claims went for payments to hospitals, with the bulk of this (11 percent) to private hospitals. Private insurance paid less than 3 percent to public hospitals--of which 2 percent was to the University Hospital. By 1992, hospital claims dropped to around 9 percent. Table 5.6 Health insurance claims by recipienta Percentage of claims payments received by: 1986 1991 1992D Hospitals 13 12 9 Private physicians and clinics 47 35 30 Laboratories 3 7 6 Pharmaceuticals 36 36 43 Other 4 9 12 TOTAL 100 100 100 Source: Kutzin (1989) for 1986 and data supplied by LICA companies for 1991, 1992. (..continued) 96 Group plans can cover as few as four employees. There are some community plans which cater for self- employed persons, although numerically they are few. PSOJ, 1993. 98 CIH, 1994. In fact, this share is probably underestimated consistently because many private clinics have pharmacies attached to them and prescription charges are often billed as one consolidated claim. 90 a. Covers four companies belonging to Life Insurance Companies Association of Jamaica (LICA) and excludes Blue Cross. b. Estimate. 5.34 The private health insurance industry expanded rapidly during the mid-1980s. This rapid growth can be seen in the number of employees with private health insurance (as distinct from individuals covered which include dependents) (Table 5.7). Between 1980 and 1986 they increased by over 73 percent from 69,000 to 120,000 employees or from about 9.6 percent to 14.8 percent of the total labor force (including self-employed). As a proportion of the formal labor market, 19 percent was covered in 1980, rising to 29 percent by 1986. Table 5.7 Employees enrolled in private group health insurance, 1980-1989 YEAR Number of employed Percentage of Percentage of persons with group work force paid employees health insurance covered by health covered by health insurance insurance 1980 69,202 9.9 19.0 1981 75,803 10.4 20.7 1982 83,077 10.4 22.1 1983 98,022 13.2 24.5 1984 106,636 13.7 25.4 1985 110,360 14.1 28.1 1986 119,922 14.8 28.9 1989 70,000 - 80,000 n.a. n.a. Source: Kutzin (1989) for 1980-1986; Cumper (1990) for 1989. 5.35 The origins and rapid expansion of private health insurance during the 1980s is best understood in light of the description above of the public financing of health care and in the inflationary and exchange rate effects on drug prices. The decline in real resources allocated by the government to the public health care delivery system, especially in the period 1983 to 1987, resulted in deteriorating quality (manifested by manpower shortages and long lines). Such waits were costly for workers who were prompted to seek private care, despite the higher financial cost. In similar fashion, shortages of drugs at public dispensaries also forced people to purchase drugs from private pharmacies. At the same time, the first half of the 1980s was a period of rapid inflation, especially for health sector prices. The implicit price deflator for private final consumption expenditure on medical care increased by more than 200 percent between 1980 to 1985.101 A major contributor was the high inflation for drugs, which increased by 130 percent between 1982/83 and 1985/6.102 Caught between declining quality of 100 Kutzin, 1989. STATIN, 1987 National Income and Product, Kutzin (1989) for 1986. 102 Taylor, 1988. 91 care in the public sector and rapidly rising costs for private care, services became increasingly costly for direct out of pocket payments. The demand for private health insurance to meet these expenses (and as a hedge against inflation) eventually became part of negotiated contracts. Then as now, employers contribute at least 50 percent of premiums and occasionally more. Because employers' 103 contributions are tax deductible as a production expense , they not only are a government subsidy, but are also an attractive way of increasing salary packages outside limits of wage guidelines. 5.36 Packages vary greatly in terms of benefit levels and premia; this is true both across firms and even within firms. Benefits packages are tailored depending on the number of persons covered (including provision for dependents), basic benefits requested by the group and premia. Companies usually offer both a basic and an enhanced scheme. Some packages offer coverage for immunization, family planning services and antenatal care. All carriers now offer major medical benefits in the event of catastrophic illness, usually with deductible provision based on accrual over several consecutive months. Most plans are, however, indemnity based with specified per use or annual maxima and/or coinsurance. Per use ceilings tend to be more generous for public services than private. For example, typical benefits included in an enhanced package provide J$700 per day for hospital room and board charges. Under the present fee schedule, J$200 per day is specified for private patients with insurance coverage. For a normal delivery, a doctor's delivery fee would be reimbursed up to J$2,560 plus up to J$2,000 for hospitalization of mother and baby. Actual delivery charges in a public hospital for a private patient are J$200 per day (including doctor's fees). A private doctor's office visit is reimbursed J$200, while the average general practitioners fee is around J$230. Private physicians' fee for a specialist consultation is around J$450, but the maximum per visit under one enhanced pan is J$350. Limits on reimbursements for pharmaceutical purchases vary depending on the plan; one enhanced plan has a maximum amount of J$3,000 with a 20 percent deductible. Public charges for pharmacy in hospitals is currently J$120 per prescription (not item); a similar prescription in a private pharmacy is estimated to be roughly 5 times that amount.'04 It should be noted that one Health Maintenance Organization (HMO) was established by Life of Jamaican in 1986. Coverage under this plan is on a precapitation basis with preferred providers covering all primary care visits to doctors and hospitalization based at Doctors' Hospital in Montego Bay. 5.37 Public hospitals are entitled to the maximum reimbursable under an insurance plan, but due to poor collection mechanisms, they rarely receive this amount, and in many cases, do not collect anything. Anecdotal evidence suggests numerous incidents where bills are provided directly to patients for submission to the insurance company. Subsequently, reimbursement is also made directly to the patient. Hospitals, in turn, do not aggressively follow-up for non-payment, perhaps due to the legacy of the period when charges were so low (relative to costs and unadjusted for inflation) that it was in fact more costly to pursue payment. 103 In principle, these deductions should be offset by taxing the contribution as part of employee's salary; however, it is not clear that in practice appropriate sums are attributed to each individual worker. 104 Shepard (1994) compared the cost of selected drugs provided through health centers (including distribution and handling charges during importation) and the same drugs through a private pharmacy. He estimated that the differential between private and public was in the range of 5 to 1. 92 5.38 The viability of the industry itself is brought into question by examining two key ratios of net claims to premia and management costs to premia. In 1988, the average ratio of claims to premia for all five companies was 77.5 percent. Management fees (including net commissions) as a percent of premia were high, ranging from 27 to 46 percent and averaging 37.3 percent. Summed, the average value of these two ratios is greater than unity, suggesting that the industry as a whole was in a loss making position. As mentioned earlier, four of the five main carriers are life insurance companies and it has been suggested that they use their health insurance line as a loss leader to attract business to their more profitable life insurance operations. This is, in fact, a subsidization of health care by life insurance companies. Figures for 1991 and 1992 suggest that the ratio of claims to premia has declined (from 68 to 56 for LICA and from 74 to 68 percent for Blue Cross). The explanation for the decline in claims is not clear. It is unlikely that either drug prices or private doctor's fees have fallen substantially. In fact, the major devaluation of the Jamaican dollar during 1993/94 suggests that drugs prices will have increased in 1993/94. Nor is it likely that health care demanded from private sources has decreased. The more likely explanation is that the companies have tightened benefits (e.g. lowering maxima or raising copayment requirements) and/or raised their premia. Difficulties in obtaining such industry-wide information on a uniform basis from the insurance companies has been notorious, leading most commentators to conclude that there is intense competition (albeit among a small number of firms) for expanding, or at least maintaining, market shares. An up-to-date figure on the size of the existing market (i.e. the number of employees covered) is not available, but some indications are that the market has been shrinking. There are reports of an increasing number of cancellations by some firms' inability to meet rising premiums (due to worsening economic conditions and rising medical costs). 5.39 Nevertheless, possibilities for expanding the market do exist. It will be recalled that approximately 40 percent of those employed had insurance. Based on the same survey, 66 percent of those who did not have any coverage indicated they would be willing to pay for premia. For those with coverage, 58 percent were willing to pay more for increased benefits, citing that some of the ceilings were too low. Technical assistance through a USAID project is, however, exploring models to expand coverage for hard-to-reach groups (e.g. rural workers, low income groups or remote communities). Low cost insurance schemes of this variety would presumably provide a similar type of coverage (i.e. doctors' visits and pharmaceutical purchases) to reduce out-of-pocket expenses. 5.40 In summary, the demand for private health insurance arises primarily to have financial access to private physicians and drugs, for routine, as opposed to catastrophic, needs. 105 Use of private health insurance to finance public hospital services in Jamaica is not extensive because the government implicitly provides this coverage by highly subsidizing hospitals costs. This is reflected by the low level of user fees, despite the recent increase, relative to economic cost of providing the service. Moreover, when the opportunities do exist for reimbursement from private insurance, public hospitals have not been aggressive in collecting the full amount stipulated under the fee schedule (which is the maximum payable under any given policy). The combination of low fees in and poor collection of insurance reimbursements by public hospitals, and tax deductions for employers, means that the government is subsidizing both the insurance industry and employers. Barnum and Kutzin, 1993. 94 Annex I Annex I: References Abel-Smith, B. and A. Creese (1989). Recurrent Costs in the Health Sector: Problems and Policy Options in Three Countries. Geneva: WHO, 9185M/9192M. Adam, S. (1993). "Increasing the Use of Private Sector Physicians by the Ministry of Health: Needs, Options and Obstacles." Boston University, CIH for Health Services Rationalization Project, Ministry of Health. Anderson, P. (1993). "The Incorporation of Mothers and Children into the Jamaica Food Stamp Programme" Jamaica Poverty Line Project, Working Paper No. 6, Planning Institute of Jamaica, Kingston, Jamaica. Ashley, D., C. Gayle, and K. Fox (1985). "A Retrospective Study of Perinatal and Neonatal Mortality at Victoria Jubilee Hospital in 1982." MOH, Kingston, Jamaica. Bailey, W. and K. Hardy (1993). "Mapping Study and Private Physicians' Survey: Opportunities for Expanded Family Planning Services in Jamaica--Executive Summary." Draft. Prepared for The National Family Planning Board. Barnum, H. and J. Kutzin (1993). Public Hospitals in Developing Countries: Resource Use, Cost and Financing. Johns Hopkins University Press for the World Bank. Brooks, S.E.H., et al. (1991). "Age-specific Incidence of Cancer in Kingston and St. Andrew, Jamaica Parts I (1978-1982) and 11 (1983-87)." West Indian Medical Journal, 1991:40-127-133. Brooks, S.E.H., et al. (1991). "Three-Year Cancer Trends in Jamaica (1958-1987)." West Indian Medical Journal, 1991:40-134-138. CIH (1994). "Jamaican Health Sector: Expenditure Based Analysis." Boston University for Health Services Rationalization Project, Ministry of Health. Cumper, G. (1993). "Should we plan for contraction in health services? The Jamaican Experience." Health Policy and Planning, 8(2):113-121. Cumper, G. (1992). "Hospitals Cost Study." Jamaica: PAHO. Cumper, G. (1990). "Investment Climate for Private Health Care." Paper prepared for Private Sector Organization of Jamaica (PSOJ), supported by USAID's Health Sector Initiatives Project. Cumper, G. (1986). "Health Sector Financing: Estimating Health Expenditure in Developing Countries." London: London School of Hygiene and Tropical Medicine, Evaluation and Planning Center, EPC-9. 95 Annex I Cumper, G., G. Walker and C. MacCormack (1985). "Evaluation of Health Care in Jamaica." London: London School of Hygiene and Tropical Medicine, Evaluation and Planning Center. Fenton, Kevin (1992/93). "Motor Vehicle Accidents in Jamaica: Their Public Health Impact and Implications for Health Policy." University of the West Indies, MSc. Public Health Medicine. Fox, K. and D. Ashley (1985). "Report on Survey of Health Status of Children Less than Ten Years In Jamaica." MOH, Kingston, Jamaica. Gertler, P., etal. (1993). "Patterns of Health Care Utilization in Jamaica: Results from a Provider Choice Model," Santa Monica, California: RAND Corporation. Gertler, P., et al. (1993). "User Fee Policy Simulations from a Provider Choice Model." Santa Monica, California: RAND Corporation. Gertler, P., et al. (1992). "High Risk Pregnancies and Maternal Health Services in Jamaica." Santa Monica, California: Rand Corporation and Kingston, Jamaica: Ministry of Health, Kingston. Govindaraj, R., C. Murray and G. Chellaraj (1994). "Health Expenditures in Latin America." Paper prepared for World Bank LAC Technical Department. Greenberg, G. (1992). "A Layman's Guide to the U.S. Health Care System," Health Care Financing Review, vol. 14, no. 1, pp. 151-169. Jamison, D. et al. eds. (1993). Disease Control Priorities in Developing Countries. New York: Oxford University Press for the World Bank. Kutzin, J. (1989). "Report of Consultancy in Economic and Financial Analysis: HSRP project." Project HOPE for PAHO. LeFranc, E.R. (1990). Health Status and Health Services Utilization in the English-Speaking Caribbean. UWI:ISER, Mona, Jamaica. Lewin, J.C. and P. Sybinsky. (1993). "Hawaii's Employer Mandate and Its Contribution to Universal Access," Journal of the American Medical Association, May 19, 193, vol. 269, no. 19, pp. 2538- 2543. Lewis, M. (1988). "Financing Health Care in Jamaica." Washington, D.C.: Urban Institute. Lewis, M. (1989). "Government Policy and the Effectiveness of User Charges in Jamaican Hospitals." Washington, D.C.: Urban Institute. McFarlane, C. er al. (1994). Jamaica: Contraceptive Prevalence Survey 1993, Executive Sununary. NFPB, Kingston, Jamaica. 96 Annex I McFarlane, C. et al. (1989). Jamaica: Contraceptive Prevalence Survey 1989, Preliminary Report. Kingston, Jamaica. Ministry of Health (1991). "Annual Report of the Health Information Unit, 1990." Ministry of Health (1992). "Communicable Disease Annual Report 1991-92. " Epidemiology Unit, Kingston, Jamaica. Ministry of Health (1992). "Hospital Statistics Report 1991." Health Information Unit, Kingston. Ministry of Finance (1993). Memorandum on the Budget 1993/94. Kingston, Jamaica. Overholt, C. (1992). "Literature Review of the Jamaican Public Health System." Washington, D.C.: Collaborative for Development Action, Inc. PAHO (1987). "HSRP project: Interim Report. Background report (Part I) prepared for Ministry of Health, Kingston, Jamaica. Peabody, J. W., et al. (1993). "Public and Private Delivery of Primary Health Care Services in Jamaica: A Comparison of Quality of Different Types of Facilities," Rand Corporation and the Ministry of Health, Jamaica. Planning Institute of Jamaica: PIOJ (1990). "Report on Selected Health Indicators, 1989." PIOJ (1990). "Report on Selected Health Indicators, April-June 1990." PIOJ: Human Resource Development Unit, Kingston, Jamaica. PIOJ (1990). "Report on Selected Health Indicators, January - March 1990." PIOJ: Human Resource Development Unit, Kingston, Jamaica. PIOJ (1993). Economic and Social Survey Jamaica 1992. Kingston, Jamaica. PIOJ (1992). Economic and Social Survey Jamaica 1991. Kingston, Jamaica. PIOJ. Jamaica Survey of Living Conditions, Kingston, Human Resource Development Program, various years. Private Sector Organization of Jamaica (1991). Summary of Investment Climate Study. PSOJ, Kingston. Saltman, R. (1992). "Single-source Financing Systems: A Solution for the United States?" in Journal of the American Medical Association, August 12, 1992, vol. 268, no.6, pp. 774-779. 97 Annex I Shepard, D. S. (1993). "Cost Recovery in Jamaican Health Facilities: Final Report," Waltham, MA: Institute for Health Policy, Brandeis University. Shepard, D. S. (1994). "Cost Recovery in Primary Health Care." Waltham, MA: Institute for Health Policy, Brandeis University. Simmonds, J.D. (1993). "The Resource Consumption of Injuries from Road Traffic Accidents on a Health Care Institution and Its Public Health Implications in Kingston, Jamaica." UWI, Department of Social and Preventive Medicine, Master's Thesis. Simmons, W. et al., (1982). "A Survey of the anemia status of preschool age children and pregnant and lactating women in Jamaica. " The American Journal of Clinical Nutrition, 35, pp. 319-326. Strauss, J. et al. (1992). "Gender and Life-Cycle Differentials in the Patterns and Determinants of Adult Health." RAND Corporation and the Ministry of Health, Kingston, Jamaica. Swezy, F. Curtis, et al. (1987). "Review of the Jamaican Health Sector and an Assessnment of the Opportunities for External Donor Support." Document prepared for USAID Mission, Kingston, Jamaica. STATIN (1991). Population Census 1991, Preliminary Report. STATIN, Population Census Office, Kingston, Jamaica. Taylor, LeRoy (1988). Government Expenditure on the Health Services: Jamaica, 1977-1986. Mona: UWI, Institute of Social and Economic Research. University of the West Indies (1989). Jamaica Perinatal Mortality and Morbidity Study, Final Report, Department of Child Health, Mona, Jamaica. United States Agency for International Development (USAID) (1989). Health Sector Initiatives Project. (Project Document). Washington, D.C. White House Domestic Policy Council (1993). Health Security: The President's Report to the American People. Washington, D.C., U.S. Government Printing Office. World Bank (1989). Social Sector Development Project, Staff Appraisal Report Number 7573-JAM, Latin American and Caribbean Department 111, Human Resources Division. World Bank (1993a). World Development Report 1993: Investing in Health. Oxford University Press, New York. 98 Annex II Annex II: Statistical Tables 1 Table 1 Annual Growth Rates, by Parish, 1960-1991 PARISH Percent of Annual Intercensal Growth Annual Total Rate Growth Rate Population, 1960-1991 1991 1960-1970 1970-1982 1982-1991 Kingston 4.4 -5.10 -0.98 -0.03 -0.56 St. Andrew 22.8 3.81 0.96 1.25 1.96 St. Thomas 3.6 0.22 1.14 0.52 0.66 Portland 3.2 0.52 0.68 0.36 0.53 St. Mary 4.6 0.55 0.53 0.21 0.44 St. Ann 6.3 0.52 1.12 0.88 0.86 Trelawny 3.0 0.87 1.06 0.34 0.79 St. James 6.6 2.11 2.40 1.55 2.06 Hanover 2.8 0.84 0.58 0.54 0.65 Westmoreland 5.4 0.32 0.53 0.68 0.51 St. Elizabeth 6.1 0.76 0.70 0.33 0.68 Manchester 6.9 0.18 1.32 1.52 1.26 Clarendon 9.0 0.68 1.23 0.49 0.84 St. Catherine 15.3 1.77 5.11 0.93 2.80 JAMAICA 100.0 1.39 1.42 0.86 1.25 Source: Population Census 1991, Preliminary Report, STATIN, 1991 99 Annex II Table 2 Distribution of disease burden, by selected age groups, 1990 C hildren under 5 C hildren aged 5-14 F e m a le s M a le s F e m a le s M a le s Percent R ank P ercent R ank Percent R ank Percent R ank C om m u nicable and Perinatai 54.3 55 .0 27.5 24 .4 I n fe c tio u s & P a r a s itic 141 1 4 .7 24.7 22 .2 D iarrhoeal D iseases 7.3 3 8.4 3 0.7 1 .3 M eningitis 2.5 10 I .9 0 .5 Intestinal H elm inths 0.1 0.0 19.7 1 16 .3 2 R esp irato ry Infections 4.2 6 4 .1 6 2.8 9 2 .0 P erinatal C onditions 35.8 1 36.2 1 N o n c o m m unicable 38.4 3 6 .4 44. 32.4 M alig nant N eoplasm s 1.9 1 .5 2.9 8 2.4 9 D iabetes M ellitus 0. 1 0.3 N utritional/E ndocrine 9.5 9.4 5.5 5 3 P rotein-E nergy M alnutrition 6.7 4 6.8 4 0.3 0.8 lo d in e D e fic ie n c y 0.0 0.0 0.0 0.0 V ita m in A D e fic ie n c y A nem ias 1.2 0 .7 4.5 5 4 5 6 N e u ro -P s y c h iatric 4.1 7 3 .2 8 11.9 3 7 9 4 C ard iovascular D iseases 4.5 5 4 .5 5 8.5 4 5 .2 5 C h ro n ic R esp iratory D iseases 3.8 8 3 .5 7 5.6 5 .1 A s th m a I.9 1. 1 4.3 7 3 .6 7 D ig estive S y stem D iseases I.9 2 .3 1.9 2. I 1 0 G enito -U rinary System D iseases I.2 1 .4 1.0 0.8 M u scu lo-S keletal S ystem D iseases 4.4 6 1 .9 C ongenital A bnorm alities I1.1 2 1 0.0 2 1.3 0 .5 Inju ries 7.3 8 .6 28.4 43 .1 U nintentional 6.9 8.6 26.0 40 .3 M oto r V eh icle A cc idents 2.5 9 3. I I 0 15.7 2 28 .5 1 P o is o n in g s 0 .3 1.1 0 .3 F a lls 1.8 3 .1 9 7.4 9 .0 3 In te n tio n a I 0.4 2.7 2 .8 H o m ic id e a n d V io le n c e 0.4 2.3 1 0 2 .5 8 D A LY s lo st 1 9 ,989 23 ,229 1 1 046 1 3 361 .0 -~~~~~~~~~~~~~~~ .0E e~~~~~~~~~~~ _ 0 rsroZ_o 101 Annex II Table 4 Malnutrition, by region, 1989-1991 Low weight for age, children Under 5 years (percent) SLC Survey All Jamaica Kingston Other Rural Urban May 1989 7.2 7.9 10.3 9.2 November 1989 8.7 8.2 6.3 7.3 November 1990 9.9 10.1 7.0 8.4 November 1991 5.2 10.7 9.8 9.0 August 1992 8.6 6.9 8.8 8.6 Source: PIOJ, "Survey of Living Conditions Report", various issues. Table 5 Inununization coverage for children under 5 years By quintile SLC, November 1991 (percent) Quintile 1 2 3 4 5 3 doses OPV 82.3 79.1 78.3 85.7 84.0 3 doses DPT 82.3 80.2 79.7 87.8 82.7 BCG 94.1 96.0 97.3 98.0 100.0 Measles 82.7 84.9 92.6 85.6 90.1 Source: PIOJ, "Survey of Living Conditions Report", various issues. 102 Annex II Table 6 Jamaican Public Hospitals, by Type Acute Care General Hospitals Type A Kingston Public Hospital (KPH) University Hospital (UWI, MONA) Cornwall Regional Hospital Type B Mandeville General Hospital St. Ann's Bay Hospital Spanish Town Hospital Savanna-La-Mar Hospital Type C May Pen Hospital Percy Junor Hospital Linstead Hospital Lionel Town Hospital Princess Margaret Hospital Port Antonio Hospital Anotto Bay Hospital Port Maria Hospital Noel Holmes Hospital Falmouth Hospital Blackriver Hospital Specialty Hospitals Bustamante Children's Hospital (BCH) Victoria Jubilee Hospital (VJH) National Chest Hospital (NCH) Bellevue Psychiatric Hospital Mona Rehabilitation Institute Hope Institute (cancer) 103 Annex II Table 7 Bed complement in public hospitals by Type, 1988-1992 TYPE Bed Complement 1988 1989 1990 1991 1992 TYPE A 1268 1137 1102 1107 1247 University 442 403 418 412 547 Kingston Public 530 504 442 408 408 Cornwall Regional 297 230 242 287 292 TYPE B 760 620 726 736 740 St Ann 140 n.a. 150 150 150 Sav-la-Mar 198 198 131 154 154 Mandeville 164 164 163 160 163 Spanish Town 258 258 282 272 273 TYPE C 1062 951 958 856 989 Princess Margaret 158 52 52 82 87 Port Antonio 125 125 125 125 125 Annotto Bay 115 116 117 116 115 Port Maria 93 93 87 87 89 Falmouth 102 103 103 103 103 Noel Holmes 52 45 51 52 51 Black River 115 115 121 110 115 Percy Junor 122 12 122 na 123 May Pen 70 70 70 70 70 Lionel Town 60 60 60 60 60 Linstead 50 50 50 51 51 SPECIALTY 2313 2319 2274 2274 2256 Victoria Jubilee 229 229 215 215 207 National Chest 96 121 73 73 73 Bustamante 244 216 244 244 244 Bellevue 1600 1600 1600 1600 1600 Mona 92 101 90 90 80 Hope Institute 52 52 52 52 52 TOTAL 5409 5021 5060 4973 5231 Source: MOH, Health Information Unit, Hospital Monthly Summary Reports. 104 Annex II Table 8 Jamaican Public Hospitals by Hospital Region, by Type Region Type Hospitals Kingston A Kingston Public Hospital (KPH) Specialty Victoria Jubilee Hospital (VJH) Specialty Bustamante Children's Hospital (BCH) Chronic Mona Rehabilitation Institute Liguanea Chronic National Chest Hospital Chronic Hope Institute St. Thomas C Princess Margaret Hospital Port Antonio C Port Antonio Hospital Port Maria C Port Maria Hospital C Annotto Bay Hospital St. Ann's B St. Ann's Hospital Montego Bay A Cornwall Regional Hospital C Falmouth Hospital C Noel Holmes Hospital Savanna-La-Mar B Savanna-La-Mar Hospital C Black River Hospital Mandeville B Mandeville General Hospital C Percy Junior Hospital Spanish Town B Spanish Town Hospital C May Pen Hospital C Linstead Hospital C Lionel Town Hospital Note: Excludes University Hospital and Bellevue Psychiatric Hospital. 105 Annex II Table 9 Midwife positions, vacancy levels and rates 1994 Total Posts Vacancies Percent Hospitals 250 128 51% Supervisory midwives 28 11 39% Midwives 222 117 53% Health Centers 379 139 37% Supervisory midwives 32 10 31% Midwives 347 129 37% TOTAL 629 267 42 % Source: Establishment List 1993 and Ministry of the Public Service. 106 Annex III ANNEX III: Calculating Jamaica's Disease Burden The calculation of Jamaica's disease burden contained in this Report quantifies the impact in loss of healthy life from approximately 100 diseases and injuries for 1990. It is measured in units of disability-adjusted life years (or DALYs). DALYs combine the loss of life from premature death (Years Life Lost--YLL) with life lost due to disabilities (YLD). These calculations for Jamaica were based on a methodology developed by the Harvard Center for Population and Development Studies for a Global Burden of Disease Study for the World Bank's 1993 World Development Report. General assumptions underlying that methodology (such as the relative value of a year of healthy life lived at different ages, the discount rate, and the disability weights used to convert life lived with a disability to a common measure with premature death) can be found in Appendix B of that Report. Cause of Death Analysis Death data as recorded by the Register General's Department were used. Each individual record included: age, sex, cause of death, year of death and year of registration. Cause of death was coded in International Classification of Disease 9 codes. The number of deaths in 1990 was constructed using the mean number of deaths from 1989 to 1991 from Communicable and Non- communicable causes in order to smooth annual fluctuations. Deaths due to injuries were adjusted for under-registration using police records. For each death, the years of life lost were defined as the difference between the actual age at death and the expectation of life at that age in a low-mortality population. Calculation of Years Lived with a Disability Years lived with a disability were based on the calculation of the years of life lost and on previous estimations of disability for the Latin American and Caribbean (LAC) and the Established Market Economies (EME) regions contained in the Global Burden of Disease study. The cause of death list was disaggregated into four categories: 1. Those diseases not present in Jamaica. 2. Those diseases also found in the LAC region but which have little or no burden due to premature death. 3. All other causes. 4. Residual disability. Disease categories that were not present in Jamaica were dropped from the analysis. Causes of disease that had no associated burden due to premature death and those which have substantially more burden due to disability than death (e.g. a ratio of YLD/YLL greater than 10) were identified. To 107 Annex III estimate the years of life lost due to a disability, disease specific inputs (i.e. the duration and age of onset for Established Market Economies; and an average of EME and LAC incidence rates for that disease) and Jamaica's population were used. For all other causes, the Jamaican Years of Life Lost by cause were multiplied by the ratio of YLD to YLL as found elsewhere in LAC for each age and sex group. Finally, after an initial estimation of YLD based on the first three categories, the disability incurred from residual causes of death was made. These causes were too small to be separately analyzed, but probably imply some associated disability. In these cases, the aggregate residual deaths are multiplied by the explained Jamaican YLD to the explained Jamaican YLL.