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8/12/2019 Policy and Ethical Issues in Nursing Heath.docx for MRS. DAWKINS
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Running Head: USER FEE POLICY 1
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 needfor the development of the healthcare user fee policy in Jamaica and its applicabilityto the nursing practice environments.
o Provide detailed explanations of two (2) priority issues/problems of the healthcareuser 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 hasimplications for nursing and health care practice in the current health care deliverysystem
o Prepare a briefing note indicating what you would say to the Minister of Healthabout the priority issue/problem in the strategic development plan.
o Prepare a position statement about the healthcare user fee policy in Jamaica on thebehalf of your National Nurses Association.
o Make five (5) recommendations for improvements in effective leadership and goodinterpersonal skills to improve standards of care delivered in the nursing practiceenvironment, 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
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Introduction
The G overnment 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, 2006-
2015). 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
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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 th e 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
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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
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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
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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
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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.
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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 de liver 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
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=PubMed&term=%20Nabyonga-Orem%20J%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=PubMed&term=%20Nabyonga-Orem%20J%5Bauth%5D8/12/2019 Policy and Ethical Issues in Nursing Heath.docx for MRS. DAWKINS
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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, t he
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
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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
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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 periodsneeds 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.
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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 Au ditor 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 searchfor 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
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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
General s 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 couldindicate 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).
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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.
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Strategic Plan (1year)
Action Situation Person in
Charge
Timeline
2012-2013
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.
Policy and
ethics
nurses, other
nurses
October,
2012
Definition of the
Problem/Issues
Shortage of Registered Nurses, heavy workload
brought about poor working conditions, increased
patient demands and internal and external migration
in search for better working conditions and more
commensurate remuneration packages
Policy
nurses, other
nurses
October
2012
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
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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)
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
Policy
nurses
December
2012
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.
Policy
nurses, other
nurses
January
February
2013
Assessment of
Resources
Sponsorship, Grants, Scholarships, Number of
nurses, level of financing needed, Qualification and
training of nurses
Policy
nurses, other
stakeholders
March
June 2013
Plan
Implementation
Carrying out pilot study at one Health Institution Policy
nurses,
Nursing
Admin,
CEO
July
December
2013
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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 ExecutiveOfficers, (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.
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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 itsmandates 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
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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
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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 forchange 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
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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 workand 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
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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 ironout 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.
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