[Reprinted: Jamaica Observer, 8-23-2020]
The global COVID-19 pandemic has raged on for more than six months and appears likely to engulf the entire year 2020. The human and economic costs have been unprecedented, perhaps making this the most devastating global catastrophe in the past 100 years.
While we hope that the pandemic will abate by 2021, it is now clear that the world will no longer be the same. The COVID-19 pandemic has exposed fundamental market frictions that present both challenges and opportunities in a post-COVID-19 world. While the immediate and direct human and economic costs are more readily quantifiable, there are numerous indirect costs and collateral damage that may not be readily obvious but become clearer with closer analysis.
This collateral damage varies from region to region and is largely influenced by the existing market. This week, we will present a series of articles focusing on the frictions that have been exposed in the health care ecosystem in Jamaica and proffer suggestions on how these may be resolved to improve health care delivery and quality for all Jamaicans.
The health care ecosystem pre-COVID-19
The health care delivery system in Jamaica pre-COVID-19 is largely based on a pre-Independence model of Government-funded health care bequeathed by Britain to all her former colonies.
To understand the origins of the frictions in the health care ecosystem in Jamaica, it is important to delve into the origins of public institutional medicine in the island. Public institutional medicine was first established in Jamaica with the opening of the Kingston Public Hospital (KPH) on December 14, 1776. What is often conveniently forgotten is that KPH was opened to serve only Jamaica’s white settlers, as the native black population were denied services at the hospital until after Emancipation in 1838.
Prior to that, blacks were only allowed “medical” treatment on sugar plantation “outhouses”. Even after emancipation, poor black patients would often have to pay bribes for admission. The result of this discriminatory admission policy was that only the white settlers and the more affluent blacks could access the “mecca” of health care in Jamaica at the time.
The full story of KPH and the two-tiered health care delivery structure of the time have been chronicled in the book: KPH; The High Seat of Medicine in Jamaica, the seminal work by Dr John Hall and the late Hector Wynter. Over time, as black emancipation and freedom took hold, the public health care systems that were once the preserve of the white settlers became open to all, and with time, evolved into places of care for the less privileged while the more affluent sought care from the private health care facilities that evolved.
The public health care system in Jamaica revolves around a network of public primary health care clinics that feed into the “tertiary” hospitals. The primary health clinics are publicly-funded and largely designed to cater for the poor. The “tertiary hospitals” are designed to cater for patients sick enough to be admitted for further treatment. This system of care allowed for most citizens to have access to basic care but did not always guarantee quality or adequacy of care, as the system is often overwhelmed by demand and limited funding.
The designated public “tertiary” hospitals have also largely become health care destinations for less affluent segments of the society and have historically suffered from underfunding resulting in a reduced capacity for optimal delivery of care.
The inadequacy of optimal care delivery in the public sector has led to the growth of private health care services that are often better funded, better equipped and more capable of providing higher quality care in a timely manner. Because of the cost of these services, they are not always affordable for the poorer members of the society, resulting in a dichotomy in the care delivery process where more affluent members of society utilise private sector health care almost exclusively, while the poorer majority depend almost exclusively on the public sector for health care needs.
Managing health care system evolution for societal benefit
The evolution described above in health care delivery system has occurred over the past 100 years in many countries around the world. Except for socialist and communist countries where health care is exclusively provided by the State, often at no direct out-of-pocket cost to citizens, almost all countries driven by free market economics have successfully evolved a duality with government-funded health care services co-existing with privately funded health care systems in a symbiotic and mutually beneficial relationship.
In Jamaica, however, there is significant asymmetry in the relationship between the public and private health care sectors. Rather than a cooperative relationship, it does appear that certain officials within the Government and particularly the Ministry of Health, view the private sector health care providers as “competitors” and are, therefore, unwilling to do anything that might be construed as providing support to their “competitors”. This unhealthy relationship hampers investment in private health care delivery systems, undermines job creation and economic growth and unfortunately deprives most poorer citizens of the enormous benefit that could be gained from the expertise and resources in the private sector health care ecosystem. Furthermore, it has perpetuated a “class system” in health care delivery that allows one standard for the poor and another standard for the affluent.
This is a fundamental friction that has been unmasked by the COVID-19 pandemic. At the height of the pandemic, the affluent could afford to attend private clinics with adequate social distancing that may not be feasible in crowded public health clinics or public hospitals where scores of patients must wait long hours in cramped waiting rooms to be seen or be admitted to crowded wards in less than optimal sanitary conditions.
Another friction that has been unmasked is the inability of the affluent to hop on the plane to Miami or other foreign destinations to seek care for the most basic health care needs as the lockdown made that impossible.
The COVID-19 pandemic has further highlighted the need for health care to be developed locally in a more cooperative and equitable way to ensure that both the rich and the poor have access to good quality health care at home and that one standard of care must apply to all patients, whether in the public or private sector, whether rich or poor. Citizens must now demand a fundamental rethinking of health care delivery and governance and determine which is preferable: “free care” access only in public facilities with limited options and varying standards of delivery or subsidised care meeting international standards through a cooperative arrangement that grants citizens access to both public and private facilities.
About the authors: Dr Ernest Madu, MD, FACC, and Paul Edwards, MD, FACC are Consultant Cardiologists at the Heart Institute of the Caribbean (HIC) and HIC Heart Hospital.