Christopher Tufton | What the World Bank said about the health system, and what we will do about it

On Tuesday, November 3, I presented to Parliament the findings of the World Bank’s (WB) Jamaica Health Public Expenditure Review Report, a study that the Planning Institute of Jamaica and my ministry requested. It asks three questions: how much Jamaica spends on health, how well that money is used, and what it buys for the people.

The WB has been a steady partner in Jamaica’s development. We asked for candour, and we received it.

CURRENT INVESTMENT

The review records real progress. By 2021/22, the Ministry of Health and Wellness accounted for roughly 16 per cent of central government expenditure, a larger share than every Caribbean comparator in the study except the Dominican Republic. That share has risen almost every year since 2013/14, through a period of tight fiscal discipline.

After inflation, central government health spending grew by about a third between 2016/17 and 2021/22. Capital spending more than doubled in real terms between 2015/16 and 2019/20, and spending on maintaining and upgrading facilities rose by around 150 per cent, though the WB notes it fell back after 2020/21.

A share of the budget, however, does not translate into money per person. Because our economy is small, our total health spending, about US$759 per person in 2021, remains well below regional and upper-middle-income averages. We give health a high priority; we are not yet a high spender.

For families, the number that matters is what they pay from their own pockets. The WB finds that, by 2019, some 68 per cent of current health spending was financed from government revenue, up from below 40 per cent in 2012, and that out-of-pocket payments had fallen to about 15 per cent, below the 20 per cent threshold recommended internationally. The remainder comes largely from private insurance and donors, not from patients at the point of care.

That achievement belongs to successive administrations: the removal of user fees in 2008 and sustained budget prioritisation since. Yet, the WB warns that the poorest fifth of households saw real out-of-pocket spending rise 42 per cent between 2012 and 2018, much of it on medicines. Financial protection is strong; it is not complete.

IMPLEMENTATION MUST IMPROVE

Non-communicable diseases cause close to four in every five deaths. Maternal mortality has shown minimal improvement in 20 years, and neonatal mortality remains too high. More needs to be done in these areas.

Too much of our spending reaches people too late. Tertiary hospitals absorb more than 40 per cent of service delivery spending while health centres receive about 20 per cent, and prevention represents under two per cent of the cost of our essential benefit package. Medicines spending has grown by 86 per cent in real terms since 2017/18, concentrated in costly drugs for advanced disease, while spending on basic blood-pressure medicines barely moved.

We have more doctors, but fewer than one in 10 medical officers is posted to a health centre, and nurses remain in acute short supply. Our Service Level Agreements with the Regional Health Authorities are not yet used to hold the system accountable for results.

It mirrors the internal assessment that produced Vision for Health 2030, the 10-year strategic plan. But agreement on the diagnosis is not a cure, and the WB is right that implementation must improve. The measure of any health system is the quality, timeliness and dignity of the care people actually receive.

PLAN AND ACCOUNTABILITY

Under Vision for Health 2030, with Inter-American Development Bank and European Union financing through the Health Systems Strengthening Programme, we are upgrading health centres such as Greater Portmore into comprehensive facilities and redeveloping Spanish Town Hospital. Jamaica Moves and Know Your Numbers target the risk factors behind those diseases.

Since 2016, we have established nearly 2,000 medical officer posts, and doctors in primary care increased by more than a quarter between 2023 and 2025. A costed human resource plan, maintenance framework, and reform of pharmaceutical purchasing, all recommended by the WB, are works in progress.

The WB’s central message is that money alone is not enough. That is why, in June, the ministry introduced an Accountability Framework across the Regional Health Authorities, the professional councils and our public bodies. Every entity is assessed against 18 standards in six areas: strategic planning and performance management, financial management, procurement, governance and internal controls, human resources, and digital transformation. Internal audit units now report directly to the ministry, and the Service Level Agreements the WB criticised are among the standards assessed.

For the first time, we are comparing those results with what patients tell us through Client Care Connect, our complaints, compliments, and feedback system. The question is simple: are our institutions well managed, and are Jamaicans feeling the benefit? The first assessments have been completed, and I will report on them to Parliament in the coming weeks. I will not claim that the framework has already improved patient care. Testing that claim is precisely what it exists to do.

Jamaica has invested more. We know where the system must improve. We have a plan, with evidence and accountability built into it. Independent assessment is the discipline of good government. The measure of our success will never be a budget line.

It will be a mother who delivers safely, a diabetic whose complications are prevented, and a patient treated with dignity and on time. That is the standard I accept, and the one by which I ask to be judged.

Dr Christopher Tufton is Jamaica’s minister of health and wellness.