Abolition of user fees: impact on access, care provided; lessons learntSaturday, February 06, 2016
Dr Adella Campbell
IN recent times the public health system has come under much greater scrutiny with its failure to meet certain standards of patient care. Consensus has emerged that at the heart of the problem is inadequate funding of the service and the extent to which the policy of no user fees has contributed to the financial plight of an already under-resourced public health system. This has become a major talking point with varied opinions, depending on the perspective from which the debaters speak.
This two-part article is based upon a study using a multi-layered mixed-method approach to evaluate and provide new insights into the impact of the abolition of user fees in the Jamaican public health system on access, care provided and the work of the professional nurse. The impact was evaluated from the perspectives of the policymaker, providers and users.
The objectives were to examine the utilisation of services in the public health facilities during the period 2006-2009; to establish whether barriers to access had remained a problem for consumers since the abolition of user fees; to analyse the effects of the abolition of user fees on the work of the professional nurse; and to identify the lessons learned for Jamaica and developing countries regarding abolition of the fees.
Prior to removal of the fees, cost was not the only barrier to accessing services. Users encountered a number of other challenges. When health services were made available at no cost, users changed their behaviours; apparently they did not trust the system to last. There was inappropriate use of the facilities, hoarding of medication, and users queued up at the facilities at early hours in the mornings.
The decision to introduce the user-fee policy was politically motivated and implemented with little or no consultation with key stakeholders, especially front-line workers such as nurses. Having been included in the then Government’s election manifesto, implementation of the policy was highly politicised. Moreover, it was hurriedly enforced. The planning and implementation processes lacked sufficient analysis of the likely effects and the support needed to ensure its effectiveness.
For a policy change of such magnitude, specific arrangements should have been put in place for timely and accurate monitoring of the possible effects; yet this had not been the case. Planning and consultation with health practitioners is important as such policies have far-reaching effects on their work and implications for how they can help to improve access.
Monitoring of the policy was done through existing systems, which captured some effects but were not sufficiently targeted to capture all the associated changes. This had implications for prompt management of the impact of the policy and for future policy development.
The experiences of African countries with similar economic situations to Jamaica were utilised by the Jamaican Government to guide the process of removing user fees. This influenced the manner in which policymakers interpreted the feasibility of the project; the aim being to remove the financial constraints that constituted a barrier to access to health care. For them, a window of opportunity presented itself and, to fulfil the mandate of the Government, the policy had to be implemented at any cost.
Practitioners, however, viewed it as political and overambitious. Dominant opinions regarding measures that might have improved the success of the policy included reverting to exemption policy; providing a basic minimum package; retaining the free care policy for children under 18 years; and provision of free services for children and the elderly. Practitioners considered these would be more realistic and practical solutions to addressing poor access to services in a resource-constrained public health system.
Users’ understanding of the policy varied. Education of end-users was also sadly lacking. While being aware of the availability of free care, most were confused about what services were in fact free. The lack of knowledge regarding the available services can be interpreted as a barrier to access, which was counter-productive and incongruous with the policy objective of improving access to health services. It also had implications for health literacy and a better understanding of the multidimensional nature of the concept of access.
Despite the implementation challenges, rapid changes took place. Of major significance was that utilisation of the public health facilities increased markedly. This was evident in the uptake of all services in the public secondary and primary care facilities. The use of Accident and Emergency, curative, and pharmaceutical services were most pronounced. Although there were reports by the Ministry of Health that utilisation rates declined after the first nine months, there was an overall increase between 2006 and 2009.
This increase resulted in practitioners being concerned about the sustained daily overcrowding at the facilities, and when patients were unable to obtain free care many elected to go back to private sector providers and pay. The Planning Institute of Jamaica reported that people from all quintiles were increasingly trending back to the private sector for health care. Officially, there was no clear explanation for this phenomenon, but it was obvious that barriers existed and there was growing disenchantment with the system.
People utilising the health services from various social backgrounds were negatively impacted, having to face travel costs, the high price of purchasing drugs at private facilities and long waiting times. Yet, they were not dissuaded and the use of private facilities increased.
Post-implementation, notwithstanding the emerging issues, perspectives regarding the policy were dissimilar between policymakers on one hand, and practitioners on the other. While policymakers remained optimistic and generally satisfied with its immediate impact, practitioners were highly dissatisfied with their working conditions, increased workloads, and lack of involvement in the policy process. Practitioners argued that, while the policy had good intentions and was benefiting those who could not afford health care, they believed that people who could afford to pay for the services should do so.
Ironically, users were generally satisfied with the services provided, even though they encountered long waiting times, drug unavailability, and decreased assessment times, inter alia. The policy also resulted in changes to the work of health practitioners generally. It further demonstrated how nurses contributed to improved access to health services as well as how health policies impact their work and other health professionals. Notwithstanding, professional nurses sought to make it work under trying circumstances. Dominant opinions expressed by research participants included a call for greater analysis, planning and consultation to have preceded the policy change. They cited low morale, lack of recognition, poor remuneration, poor working conditions, overcrowding, and increased workload resulting in ill health among nurses, and reduced patient assessment times.
Even though additional staff had been employed, nurses gave accounts of inadequate resources forcing them to make harsh decisions regarding patient care; additional stress in monitoring overseas nurses; lack of facilities such as lounge and childcare services; misuse of the services by some persons; and hostility from patients. Nurses adopted new roles, which included crowd control, to make the policy work. Generally, the perception among nurses was that the pre-existing conditions of a resource-constrained health system had been exacerbated. In addition to working with limited resources, nurses reported having to change the manner in which they offered care.
Given the above issues and lack of adequate administrative support, it was not uncommon for nurses to resign from the public service.
Ultimately, the policy change addressed a need that existed. Increased utilisation of health services was achieved however, the policy change had serious implications for budgetary allocation, resource allocation, human resources, information transfer, and monitoring mechanisms. Inadequate funding and resources, along with a lack of additional incentives for increased workload were undermining the policy. These problems could have been averted or minimised if careful analysis had been undertaken prior to its implementation. Taken together, these results suggest that the concerns raised by nurses and other practitioners might have been influenced by the policy implementation processes.
The haste with which a no-user fee policy was introduced — arguably out of political expediency — created challenges for both providers and end-users which have continued to haunt the health sector to this day. A study examining the utilisation of services in public health facilities during the period 2006-2009 offers some lessons which, if applied, should ensure that any future policy change does not suffer the same fate.
The policy was unplanned and implemented in a precipitous manner with central government adopting a top-down approach that excluded some key stakeholders in the initial stages. Clearly, policymakers should have mobilised the necessary resources in anticipation of an increase in users attending the public health facilities. Furthermore, to achieve success and sustainability, political will and commitment are prerequisites for a policy change of this magnitude. To attain commitment, the necessary resources and funding must be provided to sustain changes and, while some resources were provided, the run on the system indicated that those were insufficient.
Team players, in particular nurses and other practitioners who were not involved in the policy change processes, felt demotivated, frustrated even, with the effects.
Implications for policy
Although the debate on user fees is progressively ongoing, there is yet to be consensus on how to reform the system. The ‘big bang’ implementation approach and the response of stakeholders suggest a level of uncertainty regarding adherence to the process. Given the serious concerns by practitioners about the impact of the policy on their work, it is important that policymakers garner the views of all stakeholders in any future policy development that might be contemplated.
A policy may be interpreted differently by different stakeholders, so, for uniformity, clear, targeted communication is required. Under the no-user-fee policy not all services were designated free and, while there was some level of uniformity across regional health authorities (RHAs), users had difficulty identifying those services for which they did not have to pay a fee.
Despite publicity via print and electronic media, a level of misunderstanding prevailed. This lack of knowledge undermined the main objective of the policy. In the future, it is important to employ simplified, unambiguous guidelines to disseminating information to stakeholders and users.
No formal, specific monitoring or evaluation mechanisms had been instituted prior to the implementation of the policy. Such mechanisms are necessary to capture early and ongoing changes, as well as to provide feedback to further enhance policymakers’ ability to improve outcomes and expeditiously address problems within the system. Additionally, a monitoring system would enhance the policy by identifying workforce issues and increased areas of utilisation as well as misuse; both creating further strain on the health system.
With the system lacking sufficient recurrent and capital budgetary support, some RHAs had to adopt creative means, such as private-public partnerships, to generate additional funding. The lack of insight into the extent to which increased utilisation would affect the already resource-constrained health facilities was apparent. There should have been extensive planning to identify reliable and sustainable sources of funding to meet the demands of the new system. Moreover, cost-benefit analysis and needs assessments would have been instrumental in determining gaps in the system. Careful attention in these areas is a must for any future policy development, and examination of the long-term effects is critical to achieving access to health services.
With the recruitment of overseas nurses in an attempt to complement staff, issues arose which point to the need for clearly defined strategies to train and retain Jamaican nurses in order to effectively manage the contentious situation. Nurses interviewed expressed concerns about working with overseas nurses. It might, therefore, be necessary to undertake an examination of the efficiency of immigrant nurses. Equally, staff turnover should be investigated to determine its impact on a cost-constrained environment such as the public health system.
Frustrated users and practitioners
That users experienced difficulty accessing the free services due to daily overcrowding in the facilities and the unavailability of prescribed medications worked against the intent of access. Given this and other factors it would be instructive to examine more closely the reasons for the shift from utilising the free services to paid health care. Also, to investigate why people were non-compliant and what factors contributed to the overcrowding.
Comprehensive research into the impact of the abolition of user fees on health outcomes and health indicators, such as mortality rates, as well as the concomitant use of alternative treatments and health services, should be undertaken. The 2006-2009 data revealed that there were variations in health indicators such as infant and maternal mortality rates, and crude death rates across the RHAs, but that more people were utilising the facilities and were generally comfortable with their current health status. However, people continued to use home remedies and other forms of treatment. Research is also needed into other known barriers to access, such as geographic location of health facilities and transportation issues, as well as the costs for users to overcome these challenges.
It is recommended that a review of the user fees policy be conducted in the current Jamaican public health system. No significant changes to the policy should be implemented until such a review happens. It is important to conduct a needs assessment to determine the gaps to any further policy change. Preparation and planning contribute significantly to the policy’s successful outcome and, as such, are mandatory.
For consensus, consultation should be undertaken with main stakeholders, such as nurses and other health practitioners to engender their support.
Resources, including human resources, funding, equipment, material and pharmaceuticals should be mobilised and regularly maintained in order to strengthen service delivery.
Institutions should be reimbursed for funds no longer generated from user fees in order to purchase supplies locally; for example, contributions toward contraceptive supplies in health centres. Sufficient funds should also be made available at parish and facility levels for small-scale local expenses.
Formal, systematic monitoring and evaluation mechanisms should be established for the existing policy and for future ones. Such systems are necessary to provide prompt and accurate feedback on the facilities’ experiences to promote early intervention. Standardised and computerised systems should be set up to track the use of services, especially pharmaceuticals, and could also prove a viable solution to the problem of patients roving between facilities or hoarding drugs.
Policymakers must actively manage the effects of the policy change on the work situation of nurses and other health practitioners. This requires addressing working conditions and remuneration. Nurses’ contribution in sustaining policy change must also be recognised and opportunities for discussions regarding impending policy changes provided.
One strategy to stave off the burnout of nurses and other health practitioners would be to fast-track licensure for nurse practitioners in order to expand their role. This is already happening internationally and urgently needs to be addressed within the Jamaican context.
In conclusion, the removal of user fees in the public health system generally had positive effects on access. However, there is the need for policymakers to mobilise resources to meet the anticipated increases in demand, hold consultation with key stakeholders, and monitor and evaluate change.
Adella Campbell, PhD, is a graduate of Victoria University of Wellington, New Zealand, and is head of the Caribbean School of Nursing, University of Technology, Jamaica.
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