Running Head: USER FEE POLICY The University of the West Indies Faculty of Medical Sciences The UWI

School of Nursing, Mona Master of Science in Nursing TOPIC: HEALTH CARE USER FEE POLICY IN JAMAICA Submitted in Partially Fulfillment for the Requirements of the COURSE: NURS 4650 Policy and Ethical Issues in Nursing/Health
ASSIGMENT

o Undertake a critical analysis of the current situation that has necessitated the need for the development of the healthcare user fee policy in Jamaica and its applicability to the nursing practice environments. o Provide detailed explanations of two (2) priority issues/problems of the healthcare user fee policy in Jamaica and its impact the on the nursing practice environment. o Develop a strategic plan to address one (1) of these priority issue/problem that has implications for nursing and health care practice in the current health care delivery system o Prepare a briefing note indicating what you would say to the Minister of Health about the priority issue/problem in the strategic development plan. o Prepare a position statement about the healthcare user fee policy in Jamaica on the behalf of your National Nurses Association. o Make five (5) recommendations for improvements in effective leadership and good interpersonal skills to improve standards of care delivered in the nursing practice environment, providing justification for each

Prepared by Student I.D. Number : 620053760 Student I.D. Number : 620052327 Submitted to: Mrs. Pauline E Dawkins (Lecturer) Date: November 14, 2012

2 USER FEE POLICY Introduction The Government of Jamaicas stated policy of health for its people is to provide the means whereby access to health care services like x-rays and diagnostic services and facilities such as clinics and hospitals would help to promote good health (MOH, National Health Policy, 20062015). However, the user fee policy that obtained then was not conducive to meeting the mandate as stated in the policy above. User fee in its simplest form was a financing mechanism levied on consumers for use of health services (Litvak, 2008). User fees were designed to offset costs relating to material and human resources among other things (Jacobs & Price, 2008). A survey carried out by The Jamaica Survey of Living Conditions, (2007) found this financing mechanism to be a passive and a significant obstruction to accessing health, especially among those who were very poor. The survey stated that more than half of the individuals who said they had an illness did not go to the hospital because they could not afford it.

Using the result of The Jamaica Survey of living Conditions as a catalyst, an administrative decision was taken by one political party forming the government of the day to abolish user fees. This decision was made without consultation from technocrats or stakeholders in a bid to fulfill election promises made in their manifesto. Consequently, since April 1, 2008, all fees for health services were abolished, thus health became accessible for all Jamaicans. Given this, this paper will seek to analyze the removal of user fees as currently obtains in Jamaica. Critical Analysis of Jamaicas no User fee Policy In a Gleaner report carried on August 8, 2012 opposition spokes man on health, Dr. Kenneth Baugh stated, that the abolition of user fee increased the disposable income of individuals to the tune of 7.8 million dollars. He continued by stating that in addition to

3 USER FEE POLICY increasing the disposable incomes, the abolition of the fees increased visits to health centres by 1.2 million visits within the first three years. Additionally, drugs dispensed decreased by 2.6 million, visits to pharmacies increased by 800, 000 and diagnostic tests increased 5.7 million (Henry, 2012). In Uganda, the results of abolition of user fee were comparable. There were increases of over 50% in the use of health care institutions and pharmacies and a close to 40% reduction in persons who medicated themselves and utilized hospitals. These figures spoke especially to those who were indigent and lived in the country areas (Pariyo, Ekirapa-Kiracho, Okui, Rahman, Peterson et al., 2009). Similarly, Penfold, Harrison, Bell and Fitzmaurice, (2007) reported an increase of close to 10% in the number of mothers who attended clinic in Ghana, after the removal of user fees, this resulted in the numbers of deliveries made and were directly beneficial to mothers who were very poor. The findings above indicate that the abolition of user fees may have made health accessible to those who were very poor and may have contributed to improvements in health conditions. Therefore, one could reasonably conclude that the Government of the day had no options, but to abolish user fees. This abolition from all indication was in an attempt to make health accessible to all, in particular those who are poorest among us. Further, it indicated, increased accessibility to health, availability of more disposable income available to offset basic commodities such as food and clothing, reduce disease states and improve longevity. The Ministry of Health (2009) concurred with the writers position stated above, they posited, The imperatives that informed the abolition of user fees are not unique to Jamaica and are as follows: user fee policy has been shown to be regressive and a major impediment to access of health. They further went on to say that in a survey of 2007, 50.8% of the poorest quintile

4 USER FEE POLICY who had a reported illness did not seek health because of inaccessibility. In addition, it purports that user fees contribute to poverty by decreasing the spendable income and assets of the poor as well as negatively affecting utilization of health resources, resulting in poor health outcomes, increase diseases and life expectancy. This situation is congruent with the Millennium Developmental Goals, which seeks to combat issues pertinent to health such as poverty, hunger and disease (The Millennium Developmental Goals are a part of a multilateral agreement made in conjunction with World Health Organization with all members states of the United Nations). Jacobs et al., (2004) further support The Ministry of Health position by stating that user fee was a medical poverty trap. As a lower-middle income country, Jamaica has difficulties balancing it priorities, given that we have always been borrowing from multi-lateral agencies such as the World Bank and the International Monetary to offset debts/expenditure and stabilization of the national currency. (International Monetary Fund, 2012). This is supported by Statin (2102) figures that showed imports exceeding exports by approximately four million US dollar for the period 2006-2011. This leaves preciously little funding to combat changes in demography, epidemiology (PAHO, 2009), constraints in resources, such as human resources, machinery and equipment, which has always been with us. Therefore, these issues suggest that the objective of the user fee was to offset some of these costs, albeit in a small way. Opponents of the user fee policy would argue against the position stated above, with the view that it brought about limited access to health care due to its costs. Price et al, (2008) concurred with this position, by stating that user fees resulted in low accessibility of service and decrease quality of care due to high costs to consumers. However, proponents would argue, that today, four years post removal of user fees, the challenges far outweighs the benefits that this

5 USER FEE POLICY system has brought. The intended benefits as stated before were access to health by all Jamaicans irrespective of where they were, home or abroad, this included the poor as well as the affluent, it sought to increase accessibility to health and ultimately life expectancy. Statistically, there is a small difference in life expectancy over the periods; Index Mundi (2012) placed it at 73.43 at birth in 2008 and 73.59 at birth in 2012. Statistically, though small, it does suggest that the overall quality of life and human resources may have decreased since the abolition of user fees. In addition to the decrease in human and material resources, challenges such as extended waiting time, exploitation of the system by affluent individuals and exorbitant cost for services have become norms. In 2010, costs for services rattled up an approximately US $47 million dollars (in excess of JA $4billion dollars) (Hall, 2010). This situation is alarming, despite its intended purpose, the no user fee policy has created more stress on a tax system supposedly on crutches. In addition to the tax burden, it appears that the authorities did not factor human (workers) and material (equipment) utilization into its overall projection when user fees were being removed in Jamaican health care facilities. Ridde, Roberts and Meessen, (2012) agreed, by stating that policies relating to no user fees in middle and low income countries were enacted despite the presence of dysfunctional health systems. Consequently, the health system in Jamaica is threatened by a chronic shortage of nurses, doctors and pharmacists especially given a projected increase in patient numbers. These workers, in particular, nurses are under paid, over worked and abused by patients who become tired of waiting in long lines. Sains (1999), Schnieden and Marren (1995) supports this position by stating that long waiting times resulted in frustration, which in turn caused patients to become abusive. Schnieden et al, (1995), supported their findings with evidence that showed that eight out of every 10 verbal abuse was related to long

6 USER FEE POLICY waiting times. Given this, some nurses opt for other countries where pay packages seem more commensurate. Mullings and Paul (2007) supported this argument by stating that job opportunities with more commensurate salary offers have lured away many health professional from the Caribbean. Ridde et al (2012) concurred with the projected increase in patients seeking health and the frustration of caregivers in their study. The study found that immediately post user fee, there was an increase in service utilization, and workload for staff members. These members of staff, in relating to the abolition of user fees, stated that they felt exploited, burnt out and demotivated.

Adding to the staff shortage and demotivation, is the issue of access to drugs and other equipment, often drugs that are prescribed for patients cannot be had due to procurement costs and outstanding sums owed to suppliers (Auditor Generals Department, 2011). Ridde et al (2012), Parker and Lewis, (1991) supported this position by stating that the unavailability of drugs and delays in the distribution of consumables, contributed to the disruption of functions with the health system following the removal of user fees. This suggests that consumers may have no option but to purchase the drug/tests at private pharmacies or labs, or source it from elsewhere or die if they cannot afford it. A report by WHO (2012) statistics stated that for 10, 000 persons there were 19 available beds across Jamaican Hospitals. This situation suggests that there is a dichotomous relation between what is planned and what occurs; how can 19 beds facilitate 10, 000 persons. This further suggests that persons, who are really in need of a bed, may die if they cannot afford a private one. In addition to the unavailability of drugs and beds, consumers have to wait an inordinately long time (which leads to overcrowding) to access, diagnostic, operative and generally services. This situation suggests that the Ministry of Health has not met its mandate of making health accessibility to all, which was to increase the

7 USER FEE POLICY availability of disposable income, reduce illness and increase life expectancy, especially for the poor.

Others factor that may be impediments to increased disposable income, reduction of illness and increased life expectancy for the poor is the issue of excessive waiting and overcrowding. In addition to making consumers angry, excessive crowding and waiting,

negatively influences productivity levels and quality care. To access care, employees request time off from work, only to return home in futility on most occasions. If they were seen, it took the entire day, with a referral or an appointment being the result at times. A referral or an appointment meant further time off from duty, resulting in additional loss of productivity. One study has shown that apart from the initial stages, the number of persons accessing the services post abolition of fees had leveled off and declined in some instances (MOH, 2009). Another survey done among households indicated that the no user fee policy has prevented at least one out of every five individuals from accessing health services (National Report on Jamaica Millennium Developmental Goals, 2009). This suggest that some persons either cannot or will not waste their time in a health facility not knowing if they would be seen or their situation remedied. This situation is grave, 20% of those interviewed were unable to access health services, when the no user fees objective was to make health accessible to all. Given this, the no user fee policy needs an urgent redress from all the stakeholders, as it is not meeting its intended purpose of quality health care for all. Then there other issues such as monitoring of individuals who live abroad and utilize the services (especially those in operative, lab and diagnostic areas), those who are affluent as well as those who are holders of health insurance cards to ensure that they pay.

8 USER FEE POLICY In Jamaica, some major business places and some small ones offer health insurance (such as Sagicor and Medicus) for its employee to access health, often in partnership with the government who contributes huge sums of monies to cover premiums for those employees. (Sagicor Life of Jamaica, 2009). It is interesting to note that some of the employees do not utilize their health cards, which leaves one to wonder what happens at the end of the year to the portions of money allocated by the government. The abolition of user fee is not a bad situation in and of itself, but those who can pay should pay, either by cash or by card. Refusing to pay through either method needs an urgent redress as it further drain the coffers of much needed funding. Anecdotally, as stated before, Jamaicans living abroad comes to Jamaica to utilize the diagnostic, lab and operative services, they do not pay, though they can afford to. Again, a situation such as this, suggests continued drainage from the financial covers. If this is so, it indicates that policy makers need to put in place the necessary systems to correct this situation as provision resources and financing are of paramount importance to quality health care.

All well thinking individuals would agree that quality care in health needs resources and financing. A study conducted in Uganda on the abolition of user fees concurred with this position. The authors, Nabyonga-Orem, Karamagi, Atuyambe, Bagenda, Okuuonzi et al (2008), found that the abolition of user fees resulted in improvements in quality care. Factors that contributed to this improvement were sustainable systems modification and targeted increased allocation to the health sector. However, the budgetary allocations for health in Jamaica for the last three years did not indicate that. In 2010, it was a measly 5.3% of the overall budget, a little more than 29 million dollars, subsequent to a half million-dollar increase due to concerns about the governments ability to deliver on its no user fee policy (Hall, 2009). In the 2010/2011 budgetary estimations, the figure was 33.4 million (Hall, 2011) and for 2011/2012 it moved

9 USER FEE POLICY down to 32 million dollars (Hall, 2012). It must be noted that all the figures were well outside the required 10-15% that is recommend for the health sector (National Report of Jamaica on Millennium Goals, 2009). Further, the figures above indicate that a total abolition of user fees may not be the solution for the health sector; they suggest that the no user fee policy has served to weaken an already fragile health sector.

Following on from the possibility of contributing to the fragility that now obtains in the health sector, the abolition of user fee policy (though good in its intent) without adequate finance, human and material resources to fund and maintain it, is just as bad as not having access to health care. The abolition of user fee policy from all appearance was built on political expedience, without consideration on how the different forces and factors would interplay. Moat and Abelson, (2011) commenting on the abolition of user fee in Uganda posited, the development of policy in low and middle-income countries is complex, and the influence of international and domestic actors who are often members of broad global policy networks must be considered at each stage in the policy cycle. This situation may indicate that the steps in formulation of the policy cycle in relation to the no user fee policy were either not followed or not followed closely. These include identification of the real issues, its development, consultation and proper coordination. Further, it indicates that not all the pivotal stakeholders were involved in the process, which may be a reason its real purpose has not been achieved. The purposes of the abolition of user fees were to ease the burden on the poorest of the poor by making health more accessible to them, increasing their disposable income and life expectancy (Ridde et al., 2008). (Anecdotally) Some individuals (both poor and otherwise) have benefited from the no user fee policy, by accessing services (operative, lab and diagnostic), that hitherto would have cost thousands of dollars. Thus, increasing their health and prolonging their

10 USER FEE POLICY lives; this to some extent would have met one of the mandates of the no user fee policy. However, with all the issues and problems highlighted on the no user fee policy, some would question whether the initial objectives met. Opponents of the removal of user fees would respond with a resounding no. Two of the priority issues that affect the nursing practice environments are the provision of equipment and workforce utilization. Both of these factors have had negative effects on the quality of patient care and the wellbeing of the nurse as highlighted in this study. Arising from this situation are issues such as, overwork and burn out of nurses, which may lead to errors. Explanation of Priority Issues (Provision for workforce and equipment)

Introduction of the no user fee policy in Jamaica suggested that more poor persons would have access to health. This situation indicates that there would be a need for an increase or more efficient use of human (nurses) and material resources. For the purposes of the priority issues, the term workforce will represent nurses, unless otherwise stated. The Panamanian Health Organization regional office for World Health Organization for this side of the world, in a 2009 release that spoke to Jamaica progress on health for all 2000 found that there was a shortage in workforce (nurses). The report stated that, There is a serious shortage and imbalance in the supply of trained nurses for service in the private and public health systems. This concurred with Mullings and Paul (2007) who stated that current and frequent enrollment by foreign employers have lured away many nurses to more developed countries, consequently migration is most frequent in this category of health workers. From this, could infer that there is a dichotomy between supply and demand of the (workforce) nurses, which indicates that there is a need for an urgent redress. The report went on to say that changes in demography, epidemiology and health service organizations made it necessary for new groups of health workers to be trained, while

11 USER FEE POLICY paying attention to training in the areas most needed (PAHO, 2009). Further, it stated that both hospitals and health centres need to combine their service so that new areas for care and leadership strategies can be identified that would foster greater use of human resources (PAHO, 2009). This suggest that plans such as the training of new staff to deal with non-technical nursing functions such as bed baths, temperature, pulse and respiration needs to be put in place. Further, it could indicate that there needs to be a change in existing nurse-patient cadres, which would allow nurses to give better care to patients. It also indicates that there may be a need for improvements in the terms and conditions of employment for nurses. For example nurses who are acting in post that are clearly vacant need to be appointed, adequate vacation and rest periods needs to be given when due, if implemented, these will assist in retaining experienced and qualified nurses, so that quality patient care can be maintained. The findings by PAHO also suggest that areas of integration and efficiency are also needed, for example, hospital and clinics should not duplicate care, that is minor cases should be seen at the health centres, which would allow for the major cases to be seen at the hospitals. In addition, emphasis should be placed on areas such as absenteeism and punctuality, which would increase efficiency, decrease overwork and burn out of nurses and reduce long waiting times for patients. The large crowds that converge at hospitals on a daily basis, since the abolition of user fees, indicates that the need for training of new staff is pertinent. Effective leadership will not only train and integrate new nurses, but will deploy them where they are most needed; this deployment will assist in decreasing waiting time, prevent burn out and increase the overall quality of nursing care. Index mundi (2012) stated that more than 50% of the population was living in urban areas, which suggest that most of the nursing staff is needed in urban practice settings.

12 USER FEE POLICY On the contrary, ineffective leadership can lead to nursing (other categories of workers) shortages resulting from inadequate deployment of new and trained staff. This situation is supported by an audit conducted by the Auditor Generals Department (2011). The audit found that the lengthy delays experienced in obtaining prescription drugs by consumers were brought about by a shortage of pharmacists due to improper employment and retention strategies by the Ministry of Health. This situation has lead to over work of staff (brought about by an increase in utilization of access) chronic tiredness, fatigue and burn out, especially with measly pay packages which forces staff members (in particular nurses) to work overtime. Being constantly tired and overworked with nothing to show for it, forces the workers, especially, nurses to search for better working condition and remuneration packages. The search for better working conditions and pay packages ultimately leads to migration and depletion in the workforce. An article entitled, Spencer says willing to review user fees policy carried in Wednesday, January 5, 2011 edition of the Observer, supports this view. In the article, then opposition spokesperson (now minister of health) on health Dr. Fenton Ferguson stated that the policy to abolish user fee had several blemishes. Dr. Ferguson went on to say that the policy caused a decline in the number of bed spaces, a decrease in the supply of drugs, shortage in staff and a large-scaled exodus of nurses in addition to being indebted to companies who credited and supplied goods (Henry, 2011). This situation indicates that the exodus of senior nurses may leave new graduates to fend for himself or herself with no one to mentor them. With no role model, junior nurses would be more prone to make errors, which would negatively affect patient care within practice environments. In addition to workforce shortage (nurses in particular), there is the issue of inadequate material resources brought about by wear and tear from increased and constant usage and a lack

13 USER FEE POLICY of funds to repair old or purchase new machinery. To begin, there is no money in the coffers to buy drugs, as outstanding sums of monies are owed to suppliers exacerbated by an increase in demand brought about by the no user fee policy. A performance audit conducted by the Auditor Generals Department (2011) on MOHS Management of the supply of prescription drugs supported this view. The audit found that the MOH owed more than 1.1 billion dollars to its main supplier. Pharmacies experienced stock out and low levels of drugs, and had no options but to purchase drugs from private firms at higher costs of 796 million which prevented savings of up to 202 billion. A situation such as this, strongly suggests that the no user fee policy is constantly leaking money out of the government coffers. Offsetting this leakage of funds could indicate an increase in taxation on items such as basic food and clothing, which would most affect the poor; thus defeating the main aim of the policy. Additionally, the audit found that medications were not stored in their appropriate environment to maintain potency. This situation is grave as it suggests the potential for spoilage of medication and decrease effectiveness to patient when administered. Further, it indicates, wastage, as medications should be discarded when loss of potency is indicated, which would require additional funds to replace them. Finding additional funds to replace medication storage that was poorly managed in addition to an inability to find financing for the purchasing new drugs, paying suppliers, training and retaining new staff members, especially nurses, is akin to pulling needle out of a haystack. From this situation, there may be a need for the Government to meet with all involved stakeholders urgently, so that measures can be implemented to combat these two factors (workforce and equipment).

14 USER FEE POLICY Conclusion Anecdotally, proponents of the removal of user fees have articulated that persons have been able to access health services that were impossible prior to April 1, 2008. Laboratory, diagnostic and consultation services became free of charge, thus making them available to the common person. However, opponents of this policy have argued that it has had its shortcomings, and may have been made out of political expedience, as previously mentioned; since little consideration was given to interplay of forces such as human and material resources. Further, argues the opposers, removal of user fees have been a failure since it has contributed to longer waiting time, loss of production and burn out of staff members, in particular nurses. However, it is the opinion of the writers of this article that it would be quite useful if government implemented measures that provides a balance between those who can and cannot pay. This measure, in addition to providing much-needed funds for the coffers, would offset the cost of some resources, such as drugs and equipment as well as improve nursing practice environments, while catering for the poorest among us. The authors further believe that collaboration between the private and the public sectors would go a far way in correcting the dichotomy that now exists between supply and demand in the health sector. National Developmental Plan, (Vision, 2030) supports this position and further adds, The private sector is largely the leader in the categories of new technological initiatives and health modalities.

15 USER FEE POLICY Strategic Plan (1year) Action Situation Person in Charge Clarifying Values and Beliefs Vision statement: To increase nursing autonomy, working conditions, recognition and nursing cadre, so that quality patient care can be maintained. Mission statement: To provide quality nursing care which is dependent on an adequate and efficient cadre of nurses. We value our colleagues and patients welfare alike, therefore, we seek to find ways to combat the situations brought about by the abolition of user fees. Further, we consider the retention and autonomy of nurses as integral components within the workforce. Definition of the Shortage of Registered Nurses, heavy workload Problem/Issues brought about poor working conditions, increased patient demands and internal and external migration in search for better working conditions and more commensurate remuneration packages Analyzing Strength and opportunities Strengths and Opportunities nurses, improvement in patient care, getting quality service for less, increase in efficiency, increase nurse retention, Policy nurses November 2012 Policy nurses, other nurses October 2012 Policy and ethics nurses, other nurses Timeline 2012-2013 October, 2012

16 USER FEE POLICY increase in public perception of nurses, increase vote for government, reduction in waiting time Analyzing Weaknesses and Threats Weaknesses and Threats - Poor work conditions, lack of resources, lack of autonomy, others workers in workforce, lack of initiative from policy makers, lack of funding, negative view of nurses, division among nurses Determining Goals and Objectives We hope to achieve the following at the end of one year: Presentation of proposal to Government, Commence training of nurses, Increase nurse autonomy, Retain nurses and improve patient care. Assessment of Resources Sponsorship, Grants, Scholarships, Number of nurses, level of financing needed, Qualification and training of nurses Plan Implementation Carrying out pilot study at one Health Institution Policy nurses, other stakeholders Policy nurses, Nursing Admin, CEO July December 2013 March June 2013 Policy nurses, other nurses January February 2013 Policy nurses December 2012

Briefing Note to the Minister of Health Subject: The Abolition of User fee Policy Prepared by: Horace and Shana-kaye Williams (MScN Students, UWI, MONA)

17 USER FEE POLICY Date: November 14, 2012 Submitted to: Honorable Minister of Health, Dr. Fenton Ferguson Issue: The abolition of user fees policy instituted in 2008 is not working. Issues such as long waiting time for patients, lack of human and material resources and limited funding have militated against it. The Auditor Generals report of 2011 showed that the government owed at least 1.1 billion dollars to creditors for the purchase of drugs (in addition to loosing close to 202 billion in savings) and PAHO report of 2009 showed that there was atleast a 50% shortage of nurses, which was due partly to migration from the sector. Sir, we are proposing the following options to fix the problems: Training and retention strategies for nurses such as appointment in post where there are clear vacancies, this will help to prevent the migration of qualified and experience nurses. Increased autonomy for nurses Nurses who are practioners should be allowed to work on their own, which would offset the large crowds that visit the health centres and hospitals on a daily basis while at the same time costing less. Using nurse administrators to function, as Administrators and Chief Executive Officers, (having acquired the qualification, expertise and the knowhow) would better run the health agencies, giving value added service. Dismantling of the Regional Health Authorities Returning health to central government, using nursing as managers, prevent duplication of functions. Government would save funds that could be used to offset costs incurred from the abolition of user fees. This proposal would translate into, increased quality patient care, cost saving measures for the government and retention of nurses, which would assist in alleviating other problems brought about by the abolition of user fees. Adoption of the proposal will make the Government look good in the eyes of the people, which would mean more votes at the polls.

18 USER FEE POLICY

Position Statement on User fee policy Effective Date: November 14, 2012 Purpose: The aim of this statement is to outline the position of the Nurses Association of Jamaica on the abolition of the user fee policy. Nurses Association of Jamaicas position statement: Registered Nurses are bound legally and ethically as stated by the nurses and midwife act of 1966, to give quality care, this policy statement does not seek to define those legal and ethical issues. However, it seeks to define factors that would prevent the registered nurse from giving quality care since the abolition of user fees. Background: Registered Nurses play an important role in the health care delivery system. One of its mandates is to promote quality patient care, but since the abolition of user fee policy, this mandate has faced serious challenges. These challenges include lack of material and human resources, resulting in over work, burn out and abuse of Registered Nurses. Patients abuse nurses when they become angry due to extended waiting time. Having no other way to vent their frustration, it is directed towards nurses. Additionally, having little or no resources to work with and poor incentives adds to the nurse inability to provide quality care. In response to these factors, nurses have sought to find employment in private and international sectors, which are less hostile, provide better working conditions and pay packages that are more commensurate to their qualification. The internal and external exodus of experienced nurses, leave less

19 USER FEE POLICY experienced nurses to fend for themselves. Given this, among other factors, the quality of patient care has depreciated. Therefore, to address this situation, it is cognizant that policy makers employ a numbers of strategies. Among the strategies that need to be employed are: 1. Registered Nurses should be allowed: to maintain his or her self-awareness in relation to unsafe limitations related to competence, take time/day off in situations where he or she is tired, stressed or over worked and patient care may be compromised. To delegate as appropriately fit, non-technical assignments to non-technical or assistive personnel and advocate for manageable staff-patient ratios, especially in cases where nurses feel they are not competent. 2. Nursing Administration should: Provide annual/departmental leave for all registered nurses, set equitable time off , listen to and accept input of nurses where applicable. Provide adequate recreational area for rest during break period, identify patient outcome in relation to staff compliment, suggest change in cadre and create a patient objection form for nurses where assignments are perceived as beyond the competence level of the nurse. 3. Ministry of Health should: Formulate a National Policy Agenda on nursing patient ratio/levels or revise existing ones, make amendments the no user fee policy ( to facilitate those who can pay) and provisions for incentives/pay packages to train and retain nurses. Summary: the Nurses Association of Jamaica believes that the abolition of the user fee policy place registered nurses at risk for liability, resulting from an inability to give quality care, due to

20 USER FEE POLICY work overload, overwork and inadequate resources. We believe that the current situation can be remedied by the strategies given in this policy statement. Recommendation for Improvements in Effective Leadership To bring Effective leadership to this situation, we are recommending the following leadership tenets borrowed from Kurt Lewins Theory of Change (Unfreezing). The nurse acting as an agent of change will: 1. Create awareness for Change (Worth, 2004) - the nurse as change agent will believe in the change and be committed to it. The change agent will communicate the need for change to all stakeholders. For example, the change agent will say why work retention strategies, autonomy, (such as appointment of nurses in positions where there are clear vacancies, using nurse administrators as managers) pay and remuneration packages for nurses need to be changed. For the awareness to be effective, the change agent will demonstrate people skills that will get the message across to everyone, irrespective of their station in the sector. 2. Listen to Objections and Objectors (Kramer, 1997) The nurse, as an agent of change will anticipate objection and objectors called restraining forces by Lewin. Here, the nurse will demonstrate political skills, to maneuver objections, viewpoints and opposing viewpoints and effectively deal with them. By effectively dealing with objectors, the change will progress. However before that can occur, the change agent will listen to the objections, since they may be valid and valuable to the change. Additionally, the nurse will anticipate that some of the objections will come from within the health sector. For example, persons sitting in managerial position in hospitals, health authorities, nurses in

21 USER FEE POLICY supervisory position may want to hinder the change in order to keep their positions. The change agent will find ways to deal with all stakeholders who will seek to hinder the change, such as suggesting, early retirement or a merging of functions.
3.

Use the art of persuasion (Mcgaan, 2010) the nurse acting as a change agent will use the simple art of persuasion to convince important stakeholders why they need to buy into the change. Here, the change agent will display analytical skills by analyzing the advantages of the change and the financial impact it will have on nurses and the health system. These advantages and financial gains will persuade stakeholders, especially those in high places. For example, the change agent will argue in convincing ways that work and retention strategies for nurses mean an increase in quality patient care.

4. Identify rewards the change will bring (Sullivan, 2010) the nurse, as an agent of change, with knowledge of the needs of the health system, will identify and articulate the rewards that the change will bring using analytical and business skills. For example, he/she will successfully show how a change in work and retention strategies for nurses will prevent external and internal migration of those who are qualified and experienced. This retention will make more nurses available to meet the needs brought about by the abolition of user fees, in addition to giving quality care. Others possible rewards the change agent will be able to articulate are, the saving of funds and quality work, should nurses be used as managers, chief executive officers and administrators (no extra training, current knowledge of health and institution already exists). Further an improvement in autonomy for nurses such as nurse practitioners, will translate into rewards (increase in the number of persons who are seen at the health centres, while costing less to do so). Given these, the nurse as change agent will articulate that monies saved from these

22 USER FEE POLICY nursing initiatives will offset costs for much need resources brought about by the abolition of user fees. 5. Conduct or advocate for pilot study (Victorian Quality Council, 2006) a small version of the proposed change will be carried out at one of the institution and if it is successful, it will be extended to other health facilities. Victorian Quality Council (2006), in speaking to the effectiveness pilot study stated that it could highlight problems with implementing change as well as offer useful techniques for transformation approaches. The nurse as change agent will use knowledge gained from the result of the pilot study to determine how the change is implemented. He or she will build on the strengths and iron out the glitches and weaknesses identified. For example, all factors supporting the change (increased quality care) will be strengthened and those that seek to hinder it (old behaviours) will be effectively dealt with.

23 USER FEE POLICY References Auditor Generals Department. Performance Audit Report of the Ministry of Healths Management of the Supply of Prescription Drugs to Meet the Needs of the Population February, 2011. Hall, A. (2012, May 11). More than 54% of 612 billion to service loans and interest. The Gleaner Hall, A. (2011, April 15). Shaw hold tight budget. The Gleaner. Hall, A. (2010, April 10). Hefty price for free health care. The Gleaner. Hall, A. (2009, April 08). Government tightens-$548: Global economic meltdown forces Budget cuts in real terms. The Gleaner. Henry, B. (2011, May 05). Spencer says willing to review user fees policy. The National Observer. Henry, B. (2012, August 08). Opposition says no-user fee policy saved patients $8b. The Daily Gleaner. Index Mundi. Jamaica Life expectancy at birth. 2012 estimates. Retrieved on November 5th 2012 from http://www.indexmundi.com/jamaica/life_expectancy_at_birth.html International Monetary Fund. Jamaica and the IMF. October, 2012 Jacobs, B &Price, N. (2004). The impact of the introduction of user fees at a district hospital in Cambodia. Health Policy Plan. 19(5): 310-21 Planning Institute of Jamaica. Jamaica Survey of Living Conditions, 2007. Kramer, R. (1997). Leading by listening: An empirical test of Carl Rogerss theory of human relationship using interpersonal assessments of leaders by followers. Doctorial dissertation, The George Washington University

24 USER FEE POLICY Lewis, M. A & Parker, C. (1991). Policy and implementation of user fees in Jamaican public hospitals. Health Policy. 18(1), 57-8 Litvak, I. (2008). User fees as a form of cost sharing in a developing world. Retrieved on November 10th, 2012 from http://www.cwru.edu/med/epidbio/mphp439_fees.pdf Mcgaan, L. (2010). Introduction to persuasion. Retrieved on November 10th, 2012 from http://department.monm.edu/cata/saved_files/Handouts/PERS.FSC.html Moat, A. K & Abelson, J. (2011). Analyzing the influence of institutions on health policy in Uganda: A case study of the decision to abolish user fees. African Journal of Science 11(4): 578-586. Ministry of Health. (2009). Patient utilization one year after abolition of user fees. Retrieved October 3rd, 2012 from http://www.moh.gov.jm/general/latestnews/1-latest-news/69patient-utilization-one-year-after-abolition-of-user-fees Ministry of Health, National Health Policy, 2006-2015. Kingston, November, 2010. Mullings, J & Paul, T. J (2007) Health sector challenges and responses beyond the Alma Ata declaration: a Caribbean perspective. Pan American Journal of Public Health 21(2/3) Nabyonga-Orem, J., Karamagi, H., Atuyambe, L., Bagenda, F., Okuonzi, S et al. (2008). maintaining quality of health services after abolition of user fees: A Uganda case study Health Service Research. 8: 102. National Report of Jamaica. (2009). Millenium Development Goals. United Nations Economic and Social Council Annual Ministerial Review. Planning Institute of Jamaica Pan American Health Organization, Regional Office for World Health Organization (2009)

25 USER FEE POLICY Jamaica, Health for all 2000. World Health Organization Retrieved on October 3rd, 2012 from http://www.paho.org/english/sha/jamrstp.htm Pariyo, G., Ekirapa-Kiracho, E., Okui, O., Rahman, M & Peterson, S et al. (2009). Changes in utilization of health services among poor and rural residents in Uganda: are reforms benefitting the poor? International Journal of Equity Health. 8:39. Penfold, S., Harrison, E., Bell, J & Fitzmaurice, A. (2007). Evaluation of the delivery fee exemption policy in Ghana: Population estimates of changes in delivery service in two regions. Ghana Medical Journal. 41(3):100109. Planning Institute of Jamaica. Vision 2030 Jamaica: National Developmental Plan Quality Council. (2006). Successfully implementing change. Retrieved on November 9th, from http://www.health.vic.gov.au/qualitycouncil/downloads/successfully_implementing_ change.pdfictorian Ridde, V., Robert, E & Meeseen, B. (2012). A literature review of the disruptive effects of user exemption policies on health systems. Public Health. 12:289 Sagicor life of Jamaica. (2009). Government Employees Administrative Services Only http://www.bluecross.com.jm/aso/geaso/index.html Sains, J. (1999).Violence and aggression in A&E. Accident and Emergency Nursing 7: 8-12 Schnieden, V & Marren Bell, U. (1995).Violence in the accident and emergency department. Accident and Emergency Nursing 3: 74-78. Statistical Insitute of Jamaica. Government of Jamaica. November, 2012. Retrieved on November 5th, 2012 from http://statinja.gov.jm/ Sullivan, E & Decker, J. (2009). Effective leadership and management in nursing. New

26 USER FEE POLICY Jersey: Prentice Hall World Health Organization, World Health Statistics. (2012). Retrieved on November 10th, 2012 from http://www.who.int/gho/publications/world_health_statistics/2012/en/index.html Worth, R. A. (2004). Organizational change through influencing individual change: A behavior centric approach to change. Retrieved on November 8th, 2012 from http://www.entarga.com/orgchange

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