HEALTH care can be a free market in which the market, through supply and demand, dictates what services are provided, their cost, and distribution.

For the private sector to play a meaningful role in improving access to health care, we must understand the critical factors that impede access to care and create new sustainable models of care that recognise the existing impediments to inclusive care and health equity. Impediments to access and inclusive health care include poverty and its correlates, geographic area of residence in a poor or low-resource country or community, race and ethnicity, sex, age, occupational status, socio-economic status, education, and disability status. Accessing care— whether it is available, timely, convenient, and affordable — affects health care utilization. Any structure that delays access to care is an impediment to care.

Private sector role in facilitating access to care in a resource-constrained environment

Current models of care are primarily based on methods developed in more affluent societies with more formal economies and robust Government-funded programmes and social safety nets. These models of care are devoid of our cultural context and socio-economic realities and so are mostly unsuitable for lower-resource countries like Jamaica, where most members of the society are engaged in the informal sector and so lack the leverage of large corporations to negotiate inclusive health care coverage with insurance companies or serve as third-party guarantors of payment. Unfortunately, in low-resource nations with poor regulatory oversight, access to reliable and affordable health insurance products is limited for many citizens. While many reputable health insurance companies operate within ethical boundaries, a few are blinded by profits and tend to overreach, especially when they enjoy a relative monopoly, and regulatory oversight is weak or lax. For a health insurance product to be useful in improving access, health insurance companies cannot be directly involved in influencing the utilisation of services by the insured, either by actively encouraging patients to decline services, providing medical advice by untrained agents, or directing patients to facilities that may not be appropriate for their treatment simply to save money. This unacceptable interference with patient care represents a significant conflict of interest and poses a major impediment to access. Furthermore, a health insurance agent engaging in the practice of medicine under any guise is unlawful, unethical, and inappropriate.

The private health-care market is not immune to these calculations. Suppose the goal is inclusive health care that is sustainable. In that case, we can argue that a system that is designed to serve only the minority in the population with adequate health insurance is flawed, especially in a low-resource country like Jamaica, since there is no default position for the majority of the citizens who do not have access to coverage such as Medicare in the USA or NHS in the UK.

A system that ensures that access to care is inaccessible to most citizens in the informal sector is not in our best national interest. Fortunately, out-of-the-box and imaginative health systems innovators are beginning to design new disruptive systems of care that improve access, such as cross-subsidisation models, direct patient care models, capitation models, value-based care models, pay-for-performance models, etc. What these innovations have in common is improving the pool of people with reliable and affordable access to care while also tying compensation to performance and outcomes while limiting the interference from third parties that are more focused on profit rather than patient well-being.

The Heart Institute of the Caribbean (HIC) has been globally recognised as a pioneer and global leader in this reimagination of health-care delivery systems to ensure health equity, universal access, and inclusion. While citizens with health insurance and third-party guarantors of payment, for example, are expected to and must pay the full rate for services and procedures at HIC, we consistently subsidise the uninsured to ensure that most citizens have access to our services. While this does not sit well with some of the wealthy who disdain our subsidisation model for the poor and less affluent, we remain undeterred as we believe that our approach is anchored on a sound moral responsibility to ensure inclusive and equitable health care for all Jamaicans. We cannot justify extending such subsidies to the wealthy or to highly profitable cooperations seeking even more profit. We hope more providers will embrace these new approaches to extend care to the most vulnerable in our society. It must be remembered that the physician’s primary role is to the patient. Not to the insurance company or any third-party payer. The centrepiece of what we do as physicians must be the patient, which means all patients and not just a few. This is the basis of inclusive care and health equity. Therefore, we must embrace models of care like cross subsidisation and direct patient care models that ensure expanded access to services beyond those with third-party guarantors. The farmer in the country, the vendor at Coronation Market, the widow, and the pan chicken man, all benefit from subsidised care that grants access to high-quality care.

The physician must not be intimidated into doing what is not in the patient’s best interest to please the payer or enhance the profit for the payer. This principle is as old as time and is enshrined in the Hippocratic Oath. The Hippocratic Oath is an oath of ethics dating back to AD275, historically taken by physicians. The oath is the earliest expression of medical ethics in the Western world, establishing several important principles that continue to guide and inform medical practice today. All modern versions of the oath encompass the principle of responsibility to patients and equitable distribution of care. A current version administered by Tufts University, for example, includes as follows:

“…I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm… May I always act so as to preserve the finest traditions of my calling, and may I long experience the joy of healing those who seek my help.”

If the economics of providing appropriate and inclusive care is impractical for Jamaica, then the only access that a Jamaican patient can have is if he is willing and able to foot the financial costs of travelling abroad for care. This again widens the access gap as only the very rich can access the service. Furthermore, the access gap is exacerbated as our limited funds are transferred from Jamaica to a more affluent society like the USA, UK, or Canada by the rich in search of services not accessible in Jamaica.

The effect of resources available for health care spending and access to care can be seen when comparing low- and high-income countries. The United States consistently vaccinates more than 90 per cent of it’s children. Across sub-Saharan Africa, complete childhood vaccination averages 56.5 per cent, from a low of 24 per cent in Guinea to 95 per cent in Rwanda. In Jamaica, an upper lower-middle-income country, our childhood vaccination rates are approximately 90 per cent.

If we were to consider manpower issues in terms of the cardiologists, the continent of Africa (54 countries) has approximately 2,000 cardiologists for their 1.2 billion population or one cardiologist for 600,000 people. The United States of America has approximately 26,000 cardiologists for a population of 331 million or one cardiologist for 13,000 people. In Jamaica, we estimate about one cardiologist per 150,000 people. Our next article will look at other issues affecting healthcare access.

Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists for the Heart Institute of the Caribbean (HIC) and HIC Heart Hospital. HIC is the regional centre of excellence for cardiovascular care in the English-speaking Caribbean and has pioneered a transformation in the way cardiovascular care is delivered in the region. HIC Heart Hospital is registered by the Ministry of Health and Wellness and is the only heart hospital in Jamaica. Send correspondence to info@caribbeanheart.com or call 876-906-2107