The reality of universal healthcare in developing countries: the Jamaican experience

Dr. Christopher Tufton

Gleaner Archive – November 15, 2020

A response to the United Nations (UN) Secretary General António Guterres’ October 2020 policy brief, “COVID-19 and Universal Health Coverage,” in which he urged all countries to speed up and scale up investment in universal health coverage and in stronger health systems, starting immediately.”

Universal healthcare is a pertinent issue for Jamaica and many other developing countries. In fact, all United Nations Member States, Jamaica included, have agreed to try to achieve universal health coverage by 2030. Universal health coverage means that all people have access to the health services they need, when and where they need them, without financial hardship. Given that universal coverage is a central plank of the Sustainable Development Goals, this is obviously an important objective. Despite this, the World Health Organization (WHO) estimates that at least half of the world’s people do not have access to the health services that they need. Jamaica has made steps towards realising the goals of universal health coverage and recognises universal healthcare’s significance, particularly in relation to ensuring that all Jamaicans have access to quality healthcare, and since mid-2016, has taken concrete steps towards realising that goal. In its October policy brief, the UN secretary general emphasised three aims of universal health coverage: equity in access, sufficient quality, and no undue financial risk.

A healthy population leads to a strong economy. Thus, a robust healthcare system, underpinned by access, equity, quality, and affordability, is essential to a country’s prosperity. Most countries with weak public-health systems generally share similar developmental challenges, whereas some of the most advanced and stable economies have universal health coverage. There are, however, challenges that small island developing states such as Jamaica face in financing and meeting the demands of universal health coverage.

The UN and the WHO have emphasised the importance of universal coverage in the context of the COVID-19 pandemic, pointing to the benefits of this approach. UN Secretary General António Gutteres recently stated in a policy brief issued to the world’s health ministers that universal health coverage is not only essential to end the pandemic, but it will also drive progress across all health-related SDGs. In that October 2020 policy brief, the WHO and the UN Secretary General also emphasised the three aims of universal health care: equity in access, sufficient quality, and no undue financial risk. The World Health Organization maintains the same position. Tedros Adhanom Ghebreyesus, WHO director general, has also emphasised the importance of ensuring that universal health coverage remains a priority despite the COVID-19 pandemic.


As the minister of health and Wellness for a small island developing state, I can speak first hand to the realities of universal healthcare in a context such as ours in Jamaica, which is challenged by resource constraints and competing budgetary priorities. As minister, I have led the effort to bring universal healthcare to Jamaica and have experienced the obstacles that have, so far, thwarted that effort. After four years of working towards this goal, I am here to provide a response that takes into consideration the steps we took and the socio-economic issues and challenges that kept us from going further. Moreover, I identify the ways in which the UN and other international development partners can support countries like Jamaica to overcome the barriers and achieve universal health coverage.

Jamaica is committed to universal healthcare, and we did extensive preparatory work towards this goal. Though we had a comprehensive plan, formulated by international experts in the field, and overseen by a national steering committee of high level stakeholders, we have not moved any further forward, and there are significant challenges to proceeding. Universal coverage for preventive, curative, and rehabilitative health services requires significant human and capital resources. Wealthier and more economically stable countries can afford to deliver universal health coverage, whereas countries like Jamaica struggle for a number of reasons: limited financial, human, and technical resources, and capacity. This lack of capacity manifests itself in an inability to subsidise healthcare and to establish and properly maintain institutions to manage a national health-insurance scheme. A national emphasis on debt reduction and other competing national priorities are also indicators of the resource constraints. Further, the nature of Jamaica’s socio-economic culture, where, by some estimates, 50 per cent of the economy is informal, means that measures such as imposing compulsory premiums on taxpayers to fund a national healthcare insurance system is impractical and hardly feasible. In advanced economies, where more people are employed in the formal sector, the State can more easily implement compulsory premiums, subsidise healthcare, and establish institutions to manage a national health insurance scheme and provide quality healthcare.

In Singapore, a country that boasts one of the best healthcare systems in the world, funding for universal healthcare coverage comes from a combination of compulsory savings, direct subsidies, national health insurance, and cost sharing. Similarly, in France, funding comes from compulsory as well as user fees, and central-government funding. Singapore spends one of the lowest amounts on healthcare as a percentage of GDP in the world but is able to offer quality and enviable healthcare partly because of its compulsory payment system and the ability of citizens to contribute to it. Singapore also has the technical capacity to manage its complex universal healthcare system. Jamaica is far behind in its capacity to do these things.


My position on the issue is that the UN should throw its weight behind the secretary general’s statement and provide greater support to countries like Jamaica to achieve universal healthcare. It is important that the UN, given the importance of universal coverage in winning the fight against COVID-19 and strengthening healthcare globally, intensify its focus on offering financial assistance or rallying resources from the international donor community. The UN can, and should, actively participate in developing countries’ efforts to realise this important goal. For example, the UN can also take action in other areas of support for public health at the national level, actions that would improve the overall health profile of a country. Collaboration on training healthcare personnel and helping to improve access to essential drugs are areas for immediate action. The UN could also help to drive the wellness and behavioural change agenda, thus minimising dependence on the curative approach. This is important because Jamaica’s ability to afford universal health coverage, for various services, will depend to some extent on reducing costs and encouraging citizens to lead a healthy lifestyle.

One of the barriers that Jamaica has faced in pursuing a national health insurance system is a belief by institutions such as the IMF that universal healthcare is not affordable. Given the IMF’s traditional emphasis on economic stability and debt reduction, it is not unexpected that it does not consider access to quality healthcare and equity in the healthcare system as a national priority. Jamaica has, in just the past five years, and at first under an IMF programme, emerged from decades of economic stagnation characterised by a high debt-to-GDP ratio and underinvestment in public goods, public health included. Though we are no longer under an IMF programme, we are following an IMF-type approach to our economic policy. This approach considers universal health insurance out of reach, given the stage of economic recovery that we are at. From this perspective, the COVID-19 pandemic has made universal healthcare less of a priority and a possibility given the economic fallout. The UN now has an opportunity, given its realisation of the importance of universal healthcare, especially in a COVID-19 environment, to lend its voice to these issues and engage with the IMF and relevant national, regional, and international actors on how to reconcile what appear as contradictory views.

While the statement by the UN secretary general is timely and provides us with an opportunity to reflect on universal health coverage and its importance for building a resilient and robust healthcare system that can respond to the most serious healthcare challenges, it is important for the UN to also appreciate the enormous public health and resource challenges confronting countries like Jamaica. The UN is in a position to move beyond its statement and to champion the universal-coverage agenda. This would require new advocacy and engagement with international and regional actors and a commitment to providing or procuring technical, institutional, and financial resources. With these actions, Jamaica, and other developing countries, would be in a better position to achieve universal healthcare coverage by 2030.

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