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The negative impact of user fees on the utilisation of the health services by the poor in developing countries such as Uganda and Jamaica is well documented. Therefore, various governments have been engaged in reforming public health systems to increase access by underserved populations. One such reform is the introduction of free health services. In Jamaica, user fees were abolished in the public health sector in 2007 for children under 18 years and in 2008 free health care was introduced for all users of the public health system. This study evaluated the impact of the 2008 reform on the Jamaican public health system at 1) the national level, 2) the provider level, and 3) the user level. Perspectives were sought on access to care, the care provided, and the work of the professional nurse. Participants were selected from the Ministry of Health (MOH), the four Regional Health Authorities (RHAs), and urban and rural health facilities. Data collection was done during March – August 2010, using a multi-layered mixed methods evaluation approach, incorporating both qualitative and quantitative methods. Methods included individual interviews with key policymakers (eight) at the MOH and the four RHAs, as well as a senior medical officer of health (one) and pharmacists (three); focus groups with representatives of the main practitioners in the health system including nurses (six groups), pharmacists (one group) and doctors (two groups); document reviews of the MOH and RHAs‘ annual reports, and a survey of patients (200). Views on the impact of the abolition of user charges differed across the three levels and among the health authorities, facilities, and perspectives (policymakers, practitioners and users). Patient utilisation of the public health system increased exponentially immediately following the abolition of user fees, then declined, but remained above the pre-policy level. The work of health care providers, especially the professional nurse, was affected in that they had to provide the expected and required services to the patients despite an increase in workload and constraints such as inadequate resources. The research found that, while policymakers were optimistic about the policy, providers had concerns but patients were satisfied with the increased access and the quality care they were now receiving. Users also encountered challenges that constituted barriers to access. In addition to providing further evidence about the abolition of user fees in the public health system, this research provides important new insights into the impact of the nationwide abolition of user fees, as well as the impact of the policy change on the work of the professional nurse. Equally, the findings highlighted the potential benefits, gaps, and failures of the abolition of user fees‘ policy, and will serve as a catalyst to improve the policy process regarding access to health services and the work of the professional nurse. The findings of this research will be valuable in the planning of health-related programmes for the consumers of health care in developing countries. Despite the need for further research in this area, this research has contributed to the body of knowledge regarding user fees and access to health care in developing countries.

The Abolition of User Fees in the Jamaican Public Health System: Impact on Access, Care Provided and the Work of the Professional Nurse