IN Jamaica, as in most democracies, all persons have the right to a decent minimum of health care. Beyond this minimum, however, the quality of health care a person receives will depend on that person’s ability to pay. This point has not been clearly communicated to Jamaicans, particularly in recent times. Consequently, persons’ expectations far outstrip the Government’s ability to provide the high-quality health care that is expected for all persons in our Jamaican population.

Jamaicans were given free access to all public health care institutions on April 1, 2008, but as the Government has decreasing ability to finance all aspects of health care, some persons have been required to subsidise the cost of medications (eg, filling prescriptions outside of the hospital setting when the medication is either not stocked or is out of stock), and relatives may have to purchase some items needed in the patient’s care (eg, surgical sundries) as well as provide some bed linen and supplement the patient’s meals in hospital. Many procedures, including those that require advanced technological support (for which many of our politicians fly overseas), are not accessible to most Jamaicans who have modest financial capabilities.

Employees in the public health-care system

As civil servants, doctors and nurses in the Government’s health-care system are prevented by the terms of their employment from speaking publicly on matters in the workplace that might be embarrassing to their employers, that is, the Government. The civil service’s Official Secrets Act does not permit whistle-blowing. Whistle-blowing would reveal dangers or harms that occur within an institution that lacks accountability or is unresponsive to ethical norms. On the other hand, doctors and nurses are required by their professional codes of ethics (the Hippocratic dictum of non-maleficence) to always seek to avoid or minimise harm to patients. However, due to the terms of their employment, these professionals are placed in an ethical quandary when declining standards occur at their workplace. Consequently, non-functioning equipment (no funds to service or provide needed repairs or replacement parts), inadequate supplies of basic materials (the health- care staff running short of gloves, gauze, etc), and severe understaffing occur much more often than is reported in the Jamaican media.

Professional standards

Even though the Government’s budget for health has shrunken, medical ethics and professional standards remain the same for all health-care practitioners, whether private or public. These standards are international for the various health-care professions, and do not vary as one moves from one country to another. Consequently, when a claim of medical negligence is made against a doctor, if that doctor uses a defence of “poor resources in the workplace”, he or she is unlikely to succeed against the lawsuit. The doctor has a duty to care for and treat the patient irrespective of the scarce resources. If the lack of adequate resources in the workplace caused the harm or injury to the patient, however, the judge may take that factor into account when apportioning liability.

Even where no lawsuits occur, many public sector doctors repeatedly complain about “being given a straw basket to carry water”. The very high professional standards to which they were trained and which they had to achieve in order to graduate as a doctor from university often require particular supportive manpower, supplies and tools that are sometimes lacking in their day-to-day practice within many government health-care institutions. Where inadequate resources exist, standards and quality of care may fall. Where a doctor has 40-60 patients who turn up for care in a four-hour clinic/outpatient setting, then a good quality of care (which involves adequate communication as well as management) for all those persons may be unattainable. The World Health Organisation (WHO) recommendations limit doctors to seeing 25-30 patients per eight-hour shift. This matter therefore creates an ethical conundrum, which in some cases results in ethical blunting. As the affected doctors risk being severely reprimanded or censured by their employers if they speak out publicly on the matter (the issue revolves around job security), personal frustration and demotivation may occur in the public sector workplace. Also, patients’ dissatisfaction has sometimes resulted in the verbal abuse of health care staff.

The number of posts for doctors working in government hospitals has not been significantly increased since the 1970s, although our population has increased by 33 per cent since then. This has resulted in a much greater number of patients that each doctor is required to see in the allotted time in the public health-care institutions. Consequently, doctors have less time to attend to each patient’s condition and are more likely to suffer physical and mental exhaustion. If the Government’s budget cannot provide more positions for doctors in public sector despite the obvious need, then the matter needs to be fully explained to the Jamaican society.

Priority setting

Setting priorities is a challenge for every health-care system worldwide as demand for health care outweighs the supply of resources allocated to finance it. Hence many questions may arise. Which programmes should the Government fund? Which drugs should be placed on a drug benefit formulary? How many beds and which patients should be admitted to a hospital’s intensive care unit? How many ventilators for premature and newborn sick babies should be provided in rural hospitals? Health policies should seek to protect the health of the public as well as to minimise the risk of harm. Setting priorities in medicine, health, and health policy should not only be ethically made, but also empirically based.

Where inadequate resources exist, a guide for the best method of rationing health care would see the poorest sector of the population (20 per cent) being provided with free health care (whether in health centres or in hospitals) paid for by the Government, the middle category (60 per cent) receiving a mixture of public and private care (perhaps utilising health insurance and the possible use of private wards in public hospitals), while the richest category (20 per cent) would have the option of joining in the health-care services provided for the middle category or, alternately, assuming full responsibility for their health care. The provision of health care should not only be affordable and economically sustainable, but also should be just and equitable.

Further, priority attention must be paid to reducing those background social conditions that have significant medical and health consequences (such as the current high levels of interpersonal violence across Jamaica, which require high-cost emergency interventions that further drain the health care budget).

The Government therefore needs to communicate clearly and openly to the Jamaican population on all of these matters. The time to do so is now!

Dr Derrick Aarons MD, PhD, is a Consultant Bioethicist/Family Physician who provides detailed advice in ethical quandaries.