Ernest Madu, MD, FACC and Paul Edwards, MD, FACC
Heart Institute of the Caribbean (HIC) and HIC Heart Hospital
Correspondence to firstname.lastname@example.org or call 876-906-2107
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 begin a series of articles focusing on the frictions that have been exposed in the healthcare ecosystem in Jamaica and proffer suggestions on how these may be resolved to improve healthcare delivery and quality for ALL Jamaicans.
The Healthcare Ecosystem pre-COVID
The healthcare delivery system in Jamaica pre-COVID is largely based on a pre-Independence model of government funded healthcare bequeathed by Britain to all her former colonies. To understand the origins of the frictions in the healthcare 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 healthcare in Jamaica at the time. The full story of KPH and the two-tiered healthcare 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 healthcare 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 healthcare facilities that evolved.
The public healthcare system in Jamaica revolves around a network of public primary healthcare 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 healthcare 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 healthcare 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 utilize private sector healthcare almost exclusively, while the poorer majority depend almost exclusively on the public sector for healthcare needs.
Managing healthcare system evolution for societal benefit
The evolution described above in healthcare delivery system has occurred over the past 100 years in many countries around the world. Except for socialist and communist countries where healthcare 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 healthcare services co-existing with privately funded healthcare systems in a symbiotic and mutually beneficial relationship. In Jamaica however, there is significant asymmetry in the relationship between the public and private healthcare 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 healthcare 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 healthcare 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 healthcare ecosystem. Furthermore, it has perpetuated a “class system” in healthcare 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 healthcare needs as the lockdown made that impossible. The COVID-19 pandemic has further highlighted the need for healthcare 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 healthcare 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 healthcare delivery and governance and determine which is preferable: “free care” access only in public facilities with limited options and varying standards of delivery; or subsidized care meeting international standards through a cooperative arrangement that grants citizens access to both public and private facilities.
In Part 2 of this dialogue, we will explore other lessons from the COVID-19 pandemic that we believe should undergird the new paradigm for healthcare delivery in Jamaica in the post-COVID era to achieve optimal benefit to the Jamaican public.
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