The missing middle: Why Jamaica needs better health insurance coverage

Dr. Christopher Tufton

Gleaner Archive – November 15, 2018

Jamaica has committed to the goal of attaining universal health coverage (UHC) for all residents by 2030 in the context of the Sustainable Development Goals and the Government’s Vision 2030 strategy for improving equity and developing our human capital. We are, therefore, determined to ensure access for all Jamaicans to quality healthcare services while minimising the cost they face at the time of illness.

Of the more than 90 countries currently pursuing different strategies for UHC, there is no clear evidence regarding the best path to follow towards that goal. Many countries begin by offering subsidised care to their most vulnerable populations such as the indigent or disabled. In others, formal-sector and higher-income workers have social insurance, access private health insurance, or can pay for services out of pocket.

The citizens caught between the high cost of private health insurance and the long wait times associated with public services represent a growing group that is often referred to as ‘the missing middle’. This group is increasingly exposed to potentially catastrophic costs and reduced access to care. They are predominantly composed of middle-income and informal-sector workers.

International examples of where this has been known to happen are Vietnam and Peru, where both the lowest-income and highest-income groups in the country have increased access to care over those who are middle-income (World Bank, 2015).

This also appears to be the case in Jamaica. Data from the Jamaica Survey of Living Conditions show that for individuals enrolled in the National Health Fund (NHF) and reported needing a prescription, those in the middle-income quintile were almost 20 per cent less likely to get their medications as because of the shared costs (co-payment).

Over time, NHF’s coverage of chronic disease-related medications with a subsidy has allowed hundreds of thousands of Jamaicans to get life-saving drugs at a lower cost. For many, however, the amount that is still required for their drugs remains a significant share of their household budget, and many are forced to forgo their medication or to take a less-than-optimal dosage.

The inequity of access to private health insurance in the country also likely plays a role in the phenomenon of the missing middle in Jamaica. The latest figures show that more than 40 per cent of the wealthiest report have private health insurance, compared to only 12 per cent of those in the middle-income and four per cent in the lowest-income quintile.

Even many of our civil servants are covered by government-sponsored health coverage but find the coverage insufficient for their real needs or too expensive based on their disposable income.


These people are forced into difficult decisions regarding their investments in their children’s human capital as well as savings and other consumption decisions that could contribute to national growth in the future. These results highlight the barriers to care that reduced access for both the poorest and middle-income groups within the country.

The existing insurance coverage of just under one in every five Jamaicans is well below our potential and has been nearly stagnant for years as private plans are happy to continue covering the same large groups with traditional policies.

There are more than 2.1 million Jamaicans, many of whom are in the informal sector, low income, or both; who are not fortunate enough to be covered by the private plans. As Jamaica moves forward on an affordable, sustainable path to achieving UHC, new and dynamic mechanisms to increase insurance coverage – for all – must be created.

Enabling informal-sector workers, that make up at least 40 per cent of the labour force in Jamaica, to access the health insurance benefits largely enjoyed by only formal-sector workers will be critical to achieving the improvements in human-capital development that Jamaica needs to provide sustainable and equitable growth.

This will not happen through interventions that rely solely on the public sector improving the services available or gradually allowing private health insurance to grow as the economy becomes more and more formalised.

Some disruption is needed to get both the new entrants and the old stalwarts to improve the services offered, increase the value-for-money in the services they provide, and allow more people to access those services. The case of the ride-sharing application Uber and traditional taxicabs rapidly comes to mind.

Certainly, a lot could be achieved by working with private health insurance companies within Jamaica to create new, cost-effective plans that utilise technology such as e-payments, using the available platforms and kiosks, payment schedules that match the seasonal employment of many informal-sector workers, and plans that fit their most pressing needs – diagnostic imagery and laboratory, for example to broaden the penetration of private plans to cover the growing middle class.


Eventually, the PHI plans could be coordinated within the newly developed National Health Insurance Plan so that the risks of all participants – children, low-income and unemployed, informal-sector workers, formal-sector workers, retirees – are all merged into one pool, reducing the overall average cost of health provision to the country.

While it is true that the Ministry of Health’s fee-less policy has removed financial barriers for many of our most vulnerable people, there is still a majority that doesn’t often use public services and can’t afford private care or private insurance.

Many employed informal-sector workers simply cannot take off work to dedicate the required time to do consultation in the public sector nor can they afford a private visit. Many times, the delay in accessing care for the missing middle results in a diagnosis that is more severe, and potentially fatal, compared to early intervention following appropriate preventive screenings.


Women in Jamaica are particularly at risk of falling through the cracks. Indeed, this is likely a more common scenario than you may think. It is estimated that if the avoidable death rate in Jamaica (deaths caused by non-communicable diseases that should have been avoided through appropriate care at the primary-care and self-care levels) was reduced to European Union levels, it would prevent 7,035 deaths annually.

The cost of just those avoidable deaths is estimated at more than J$1.82 billion annually. But the cost of ill health in Jamaica is even larger, with illness impacting productivity levels, absenteeism, and presenteeism within the labour market but also impacting educational outcomes for children and investment opportunities lost to the wider economy. Jamaicans who face financial problems because of healthcare costs cannot save or invest in other areas, thereby stifling economic growth.

Through expanding access to health insurance, using lower cost, more innovative private plans, and a national plan that is affordable, and which will expand over time, all Jamaicans should be able to enjoy the benefits of UHC by 2030.

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