Determinants of self-rated private health insurance coverage in Jamaica

doi:10.4236/health.2010.26081

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Vol.2, No.6, 541-550 (2010) Health

doi:10.4236/health.2010.26081

Determinants of self-rated private health insurance

coverage in Jamaica

Paul A. Bourne1*, Maureen D. Kerr-Campbell2

1Department of Community Health and Psychiatry, Faculty of Medical Sciences The University of the West Indies, Mona, Jamaica;

*Corresponding Author: paulbourne1@yahoo.com

2Systems Development Unit, Main Library, The University of the West Indies, Mona, Jamaica

Received 18 November 2009; revised 5 January 2010; accepted 8 January 2010.

ABSTRACT

The purpose of the current study was to model

the health insurance coverage of Jamaicans;

and to identify the determinants, strength and

predictive power of the model in order to aid

clinicians and other health practitioners in un-

derstanding those who have health insurance

coverage. This study utilized secondary data

taken from the dataset of the Jamaica Survey of

Living Conditions which was collected between

July and October 2002. It was a nationally rep-

resentative stratified random sample survey of

25,018 respondents, with 50.7% females and

49.3% males. The data was collected by way of a

self-administered questionnaire. The non-re-

sponse rate for the survey was 29.7% with

20.5% not responding to particular questions,

9.0% not participating in the survey and another

0.2% being rejected due to data cleaning. The

current research extracted 16,118 people 15

years and older from the survey sample of

25,018 respondents in order to model the de-

terminants of private health insurance coverage

in Jamaica. Data were stored, retrieved and

analyzed using SPSS for Windows 15.0. A

p-value of less than 0.05 was used to establish

statistical significance. Descriptive analysis was

used to provide baseline information on the

sample, and cross-tabulations were used to

examine some non-metric variables. Logistic

regression was used to identify, determine and

establish those factors that influence private

health insurance coverage in Jamaica. This

study found that approximately 12% of Jamai-

cans had private health insurance coverage, of

which the least health insurance was owned by

rural residents (7.5%). Using logistic regression,

the findings revealed that twelve variables

emerged as statistically significant determinants

of health insurance coverage in this sample.

These variables are social standing (two weal-

thiest quintile: OR = 1.68, 95% CI = 1.23 – 2.30),

income (OR = 1.00, 95%CI = 1.00 – 1.00), durable

goods (OR = 1.16, 95% CI = 1.12 – 1.19), marital

status (married: OR = 1.97, 95% CI = 1.61 – 2.42),

area of residence (Peri-urban: OR = 1.45, 95% CI

= 1.199 – 1.75; urban: OR = 1.83, 95% CI = 1.40 –

2.40), education (secondary: OR = 1.57, 95% CI =

1.20 – 2.06; tertiary: OR = 9.03, 95% CI = 6.47 –

12.59), social support (OR = 0.64, 95% CI = 0.53

– 0.76), crowding (OR = 1.14, 95% CI = 1.02 –

1.28), psychological conditions (negative affec-

tive: OR = 0.97, 95% CI = 0.94 – 1.00; positive

affective: OR = 1.11, 95% CI = 1.06 – 1.16), num-

ber of males in household (OR = 0.85, 95% CI =

0.77 – 0.93), living arrangements (OR = 0.62,

95% CI = 0.41 – 0.92) and retirement benefits

(OR = 1.55, 95% CI = 1.03 – 2.35). This study

highlighted the need to address preventative

care for the wealthiest, rural residents and the

fact that social support is crucial to health care,

as well as the fact that medical care costs are

borne by the extended family and other social

groups in which the individual is (or was) a

member, which explains the low demand for

health insurance in Jamaica. Private health care

in Jamaica is substantially determined by af-

fordability and education rather than illness,

and it is a poor measure of the health care-

seeking behaviour of Jamaicans.

Keywords: Health Insurance;

Private Health Coverage;

Social Determinants of Health Insurance Coverage;

Jamaica

P. A. Bourne et al. / HEALTH 2 (2010) 541-550

542

1. INTRODUCTION

Literature on private health insurance or health insurance

in the Caribbean, and in particular Jamaica, has been

substantially on 1) population density–i.e. coverage, 2)

coverage offerings, 3) cost of care–i.e. health economics,

and 4) acceptance (or lack of) by health service provid-

ers of certain insurance coverage. Having extensively

perused the literature review on private health insurance

and health care reform in Jamaica, it is obvious that no

study has been conducted identifying the different fac-

tors that explain health insurance coverage in this nation.

The individual utilization pattern of health insurance

coverage is highly associated over time with older adults

[1,2] as they prepare for the degeneration of the body;

but, what else do we know about those who have private

health insurance in Jamaica? Do insurers attract healthy

patients, and are high risk individuals more likely to

become insured as against their low risk (i.e. less health

conditions) counterparts? Health insurance is a con-

stituent of health seeking behaviour, suggesting that it is

equally important in any study of health, quality of life,

and wellbeing. In this study the researchers will criti-

cally examine factors that can be used to predict private

health insurance coverage by using a logistic regression

technique to explain the independent effect; and in the

process the researchers will investigate the lives of re-

spondents in order to understand those who reported

having private health insurance coverage.

Instead of providing an elaborate and extensive de-

scription of ‘health insurance’, we will give a simplified

meaning of this construct. Health insurance is protection

against medical costs owing to the possibility of injuries,

dysfunctions and other happenings that hinder the body

from performing at some functional standard. In keep-

ing with this definition, a health insurance policy is the

contract that is signed by an insurer (i.e. insurance pro-

vider) and an individual or a group, in which the insurer

agrees to pay a specific sum (i.e. a premium). Hence, the

population’s health service is partially dependent on

health insurance coverage or the welfare system of the

state. Jamaica does not have a public health insurance

system, but one for the elderly and those who have par-

ticular chronic health conditions, such as diabetes melli-

tus, hypertension, cancer or a combination. In September

2001, the Cabinet of Jamaica accepted and approved a

proposal for the establishment of a National Health Fund

(NHF) that would assists patients as well as the elderly

in Jamaicans. The individual benefits of the NHF (i.e.

public health insurance options) for the elderly and for

those with particular chronic health conditions was offi-

cially commenced in 2003 (i.e. August 1, 2003), and so

there are only data on private health insurance coverage

from 1988-2002. Despite the fact that Jamaica has insti-

tuted a free health-care service delivery programme for

its child population (below 18 years in 2006), the quality

of care which is relatively good is still surrounded by a

certain socio-psychological milieu as well as inequality

in health care offerings in the private versus the public

sector. This explains the rationale why some people seek

private health care and by extension private health in-

surance coverage [3] to meet the impending higher

medical cost of care [1,4-7] and a particular quality of

service–environment, customer service and length of

service. The current study will be examined within the

theoretical framework used by Franc, Perronnin, & Pi-

erre [8].

1.1. Theoretical Framework

A South African Health Inequalities Survey (SANHIS)

carried out in 1994 of 3,489 women ages 16 to 64 years

was used to model the determinants of health insurance

coverage. Kirigia et al., [8] sought to model health in-

surance demand among South African women. They

used binary logistic regression analyses to estimate

health insurance coverage among the sample and various

determinants of health insurance coverage. Health in-

surance coverage of the sample was determined by

socio-demographic characteristics, health rating, envi-

ronment rating, bad health choices (i.e. smoking and

alcohol consumption), and contraceptives. These were

embodied in the mathematical formula, Eq. 1:

Pij = (α + β1 Health rating + β2 Environment rating + β3

Residence + β4 Income + β5 Education + β6 Age + β7 Age

squared + β8 Race + β9 Household size + β10 Occupation

+ β11 Employment + β12 Smoking + β13 Alcohol use + β14

Contraceptive use = β15 Marital status + εi (1)

where Pij = 1 if individual I owns insurance (j = 1) and

equal otherwise (j = 0); α is intercept terms; (β’s) are the

estimated coefficients; and εi is the stochastic error term.

The conceptual framework of Kirigia et al.’s work [8]

was on two risks of health care. They believed that these

risks are (1) the risk of becoming ill, with the associated

loss in quality of life, cost of medical care, loss of pro-

ductive times, more serious cases, mortality, and (2) the

risk of total or incomplete or delayed recovery [8]. This

denotes that a person’s decision to buy health insurance

would be based on differentials between the level of

expected utility of the insurance and the expected utility

without insurance. It is this binary nature dependent

variable and the desire to determine the effect of par-

ticular independent variables that justified the binary

logistic regression technique.

Eq. 1 allows for the estimation of the individual

probability of having or not having health insurance by

some explanatory variables. Kirigia et al., [8] did not

P. A. Bourne et al. / HEALTH 2 (2010) 541-550

543

stipulate whether health insurance was public or private

coverage, and this was addressed in another research

paper. Using the same principle of econometric analysis

as Kirigia et al., a group of researchers used a single

multiple regression equation that identified explanatory

variables and the powers of particular factors that can be

used to determine determinants of those who have pri-

vate health insurance [9]. This captures a standard utility

theory model of a demand for private health insurance

coverage, Eq. 2:

Y = β0 + β1P + β2I + β3Z (2)

where the standard utility theory is expressed in the

quantity demanded of health insurance, Y, can be written

as a function of the user price of health insurance, P,

income, I, and a vector of other factors, Z or (with time

subscripts suppressed); and β1 and β2 represent, respec-

tively, the price and income elasticity of the demand for

private health insurance.

Like Kirigia et al., [8] self-rated private health insur-

ance coverage is a binary variable (1= yes and 0= other-

wise), which denotes that a logistic regression model

will be used to estimate the determinants and determine

their impact on the dependent variable, as was done by

Ahking, Giaccotto, and Santerre [9]-Eq. 3. Instead of

having a vector factor which envelopes individual char-

acteristics, this research isolates those factors including

income, unlike Eqs. 1 and 2, and added more variables

such as psychological conditions, living arrangements

and social support.

HIi = ƒ(Yi, HCi, Eni, MSi, ARi , Ei, SSi, Oi, Pi, Gi, NPi, PPi,

Mi, Fi, Di, EWi , Ai, Ri, YPi, Pmci, LLi, CRi,) (3)

where Eq. 3 is Private Health Insurance coverage, HIi, is

a function of Yi is average current income per person in

household i; HCi is health conditions of person i; Eni is

physical environment of person i; MSi is marital status of

person i; ARi is area of residence of person i; Ei is educa-

tional level of person i; SSi is social support of person i;

Oi is average occupancy per person i; Pi is property

ownership of person i; Gi is gender per person i; NPi is

negative affective psychological conditions per person i;

PPi is positive affective psychological conditions per

person i; Mi is number of males per household per per-

son i; Fi is number of females per household per person i;

Di is the number of children per household per person i;

EWi is durable goods; Ai is age of person i; Ri is retire-

ment benefits of person i; YPi is social standing of per-

son i; Pmci is cost of medical care of person i, LLi is

living arrangements of person i; and CRi is crowding.

The current study found the following determinants of

private health insurance of Jamaica (Eq. 4):

HIi = ƒ (Yi, ARi, MSi, SSi, Ei, ∑(NP i, PPi), Mi , EW i, Ri,

YPi,LLi,CRi,) (4)

where Eq. 4 is Private Health Insurance Coverage, HIi,

is a function of Yi is average current income per person

in household i; HCi is health conditions of person i; ARi

is area of residence of person i; MSi is marital status of

person i; SSi is social support of person i; Gi is gender

per person i; Ei is educational level of person i; NPi is

negative affective psychological conditions per person i;

PPi is positive affective psychological conditions per

person i; EWi is durable goods of person i; Di is the

number of children per household per person i; Ri is

retirement benefits of person i, YPi is social standing of

person i, LLi is living arrangements and CRi is crowd-

ing.

2. MATERIALS AND METHODS

2.1. Method

This study utilized secondary data taken from the dataset

of the Jamaica Survey of Living Conditions which was

collected between July and October 2002. It was a na-

tionally representative stratified random sample survey

of 25,018 respondents, with 50.7% females (N = 12,675)

and 49.3% males (N = 12,332). The data was collected

by way of an administered questionnaire. The non-re-

sponse rate for the survey was 29.7% with 20.5% not

responding to particular questions, 9.0% not participat-

ing in the survey and another 0.2% being rejected due to

data cleaning. The current research extracted a sub-

sample of 16,118 people 15 years and older from the

survey sample of 25,018 respondents in order to model

the determinants of private health insurance coverage in

Jamaica.

The rationale for the use of the 2002 data set instead

of the 2007 is primarily because of the sample popula-

tion. In 2002, the institutions that were principally re-

sponsible for the data collection used 10% of the na-

tional population to gather pertinent data on the labour

force, and this was for the Survey of Living Conditions.

It represents the largest data collected on the Jamaican

population, and data was also collected on crime and

victimization and the environment, these being included

for the first time, and omitted in subsequent surveys.

Given the nature of crime, violence and victimization in

the nation, we opted to use a survey that had crime and

the environment as among data collected. Another con-

dition for the selection of this dataset was the fact that it

was a large population, as against other years when the

population was less than 3,000. Within the context of a

non-response rate that ranges from 10 to 30 per cent, a

larger rather than a smaller sample size coupled with

some pertinent variables was preferred to a smaller sam-

ple size without the two critical aforementioned vari-

ables. Data were stored, retrieved and analyzed using

P. A. Bourne et al. / HEALTH 2 (2010) 541-550

544

SPSS for Windows 15.0. A p-value of less than 0.05 was

used to establish statistical significance. Descriptive

analysis will be done on the sampled population in order

to provide background information on the respondents;

and the enter method of logistic regression will be used

to establish the determinants of self-reported private

health insurance in Jamaica. Using the principle of par-

simony, the final model will consist of only those statis-

tically significant variables. Where multicollinearity

existed (r > 0.7), variables were independently entered

into the model to aid in determining which one should be

retained during the final model construction (i.e. the de-

cision therefore was based on the variable’s contribution

to the predictive power of the model and the goodness of

fit).

2.2. Measure

Health conditions: The summation of reported ailments,

injuries or illnesses in the last four weeks, which was the

survey period; where higher values denote greater health

conditions; it ranges from 0 to 4 conditions. Health

status is a dummy variable, where 1 (good health) = not

reporting an ailment or dysfunction or illness in the last

four weeks, which was the survey period; 0 (poor health)

if there were no self-reported ailments, injuries or ill-

nesses. While self-reported ill-health is not an ideal in-

dicator of actual health conditions as people may un-

der-report their health condition, it is still an accurate

proxy of ill-health and mortality. Household crowding:

This is the average number of persons living in a room.

Physical Environment: This is the number of responses

from people who indicated suffering landsides; property

damage due to rains, flooding or soil erosion. Psycho-

logical conditions are the psychological state of an indi-

vidual, sub-divided into positive and negative affective

psychological conditions. 18-19 Positive affective psy-

chological condition signifies the number of responses

with regard to being hopeful and optimistic about the

future and life generally. Negative affective psychologi-

cal condition means number of responses from a person

on having lost a breadwinner and/or family member, loss

of property, being made redundant, or failing to meet

household and other obligations.

Income is proxied by total individual expenditure in

USD. During the survey period, United States $1.00 was

equivalent to Jamaican $50.97. Average income (i.e. per

person per household) is total expenditure divided by the

number of persons in the household. Age: The number of

years lived, which is also referred to age at last birthday.

This is a continuous variable, ranging from 15 to 99

years. Age group is classified into three categories.

These are young adults (ages 15 to 30 years), middle

aged adults (ages 31 to 59 years) and the elderly (ages

60 + years). Retirement benefits were measured by those

who recei- ved retirement income. Private Health Insur-

ance Coverage: This is a dummy variable, where 1 de-

notes self- reported ownership of private health insur-

ance coverage and 0 is otherwise.

Durable goods: This variable is the summation of the

self-reported durable goods owned by an individual ex-

cluding houses, buildings and property. where Di



EW D

i

ranges from 1 to 28, where higher values

denote greater ownership of durable goods.

Living arrangements are a dummy variable where, 1 =

living alone, 0 = living with family members or relative.

Social support (or network) denotes different social

networks with which the individual has been or is in-

volved (1 = membership of and/or visits to civic organi-

zations or having friends that visit one’s home or with

whom one is able to network, 0 = otherwise).

Crime:



CrimeIndexi=K T





where Ki represents the frequency with which an indi-

vidual has witnessed or experienced a crime, where i

denotes 0, 1 and 2, in which 0 indicates not witnessing

or experiencing a crime, 1 means witnessing 1 to 2, and

2 symbolizes seeing 3 or more crimes. Tj denotes the

degree of the different typologies of crime witnessed or

experienced by an individual (where j = 1…4, where 1 =

valuables stolen, 2 = attacked with or without a weapon,

3 = threatened with a gun, and 4 = sexually assaulted or

raped. The summation of the frequency of crime by the

degree of the incident ranges from 0 and a maximum of

51.

Social standing is proxied by per capita population

quintile (from poorest-to-wealthiest)

3. RESULTS

3.1. Demographic Characteristics of Sample

The sample was 16,619 respondents (i.e. 48.6% males

and 51.4% females; with 39.2% young adults, 42.7%

middle aged adults and 18.1% elderly). Some 25.8% of

the sample resided in peri-urban areas; 60.2% in rural

zones; 14.0% were from urban areas; 16.8% were below

the poverty line (i.e. poorest 20%); while 18.2% were

just above the poverty line compared to 21.2% in the

wealthy quintile and 24.1% in the wealthiest 20%. Of

the sample, 97.6% responded to the health status ques-

tion. Of those who responded to the health status ques-

tion, 80.6% indicated at least good health and 19.4%

poor health. Ninety-seven percentage points of the sam-

P. A. Bourne et al. / HEALTH 2 (2010) 541-550

545

ple (n = 16,118) responded to the health insurance cov-

erage question, of that 11.9% revealed having health

insurance coverage.

Based on Table 1, poverty is substantially a rural phe-

nomenon. The findings revealed that 21.2% of rural

residents were below the poverty line (i.e. poorest 20%)

compared to 10.7% of peri-urban dwellers and 9.5% of

urban settlers. Health insurance was greatest among ur-

ban residents: Some 20.8% of urban dwellers had health

insurance compared to 17.6% for peri-urban settlers and

7.5% of rural residents. A significant statistical differ-

ence was found between area of residence and crime,

and income in this sample.

Peri-urban residents spent the most statistically on

medical care (USD 39.16 ± USD 85.77, 95% CI: USD

31.39 – USD 46.94) compared to urban (USD 30.25 ±

USD 61.47, 95% CI: USD 22.66 – USD 37.83) and rural

residents (USD 29.33 ± USD 54.15, 95% CI: USD 26.58

– USD 32.06) (Table 1)

On examination of the cross tabulation between good

health status and social standing, a statistical correlation

was found (P = 0.001) (Table 2). Table 2 showed that

the worst health was reported by those in the wealthiest

quintile (21.8%), the poorest (19.9%), the poor (18.6%)

and so on.

There is a positive statistical correlation between age-

ing and self-reported poor health (or health conditions)

of Jamaicans (P = 0.001) (Table 3). Further examination

of Table 3 revealed that 10.3% of young adults reported

poor health compared to 17.4% of middle aged adults

and 43.6% of the elderly

Table 1. Demographic characteristic of sample by area of residence.

Rural % (n) Peri-urban % (n) Urban % (n) P

Age group 0.001

Young adults 38.3 (3833) 41.0 (1760) 39.7 (923)

Middle age adults 41.6 (4160) 44.2 (1895) 44.6 (1039)

Elderly 20.1 (2010) 14.8 (634) 15.7 (365)

Health insurance coverage 0.001

Yes 7.5 (722) 17.4 (726) 20.8 (471)

No 92.5 (8969) 82.6 (3442) 79.2 (1788)

Gender 0.001

Male 50.4 (5041) 46.8 (2006) 44.3 (1031)

Female 49.6 (4962) 53.2 (2283) 55.7 (1296)

Per capita income quintile 0.001

1 = Poorest 20% 21.2 (2118) 10.7 (458) 9.5 (222)

2 22.0 (2196) 13.3 (572) 11.2 (261)

3 20.8 (2085) 18.7 (800) 16.7 (388)

4 19.8 (1978) 22.7 (972) 24.3 (565)

5 = Wealthiest 20% 16.2 (1625) 34.7 (1487) 38.3 (891)

Marital status 0.001

Married 25.5 (2460) 26.9 (1115) 21.0 (475)

Never married 66.6 (6433) 66.4 (2755) 71.6 (1619)

Divorced 0.6 (56) 1.0 (41) 1.2 (26)

Separated 1.1 (104) 1.2 (49) 1.4 (32)

Widowed 6.3 (610) 4.5 (187) 4.8 (108)

Crowding mean (SD) 1.77 ± 1.24 1.75 ± 1.28 1.72 ± 1.18 0.216

Crime index 1.74 ± 7.37 2.34 ± 8.08 2.83 ± 9.30 0.001

Medical expenditure1 mean (SD) $ 29.33±$54.15 $ 39.16 ± $85.77 $ 30.25± $61.47 0.012

Income2 mean (SD) $ 5496.12 ± $4860.97 $ 7534.74 ± $5544.26 $ 8779.26 ±$10568.69 0.001

1Medical Expenditure is expressed in USD: United States $1.00 was equivalent to Jamaican $50.97 (during surveyed period)

2Income is expressed in USD: United States $1.00 was equivalent to Jamaican $50.97 (during surveyed period)

P. A. Bourne et al. / HEALTH 2 (2010) 541-550

546

Table 2. Good health status by social standing (Per capita population quintile).

Social standing (Per Capita Population Quintile)

Good health status

1=Poorest 2 3 4 5 = Wealthiest

Total

Poor 19.9 18.6 17.9 18.4 21.8 19.4

Good 80.1 81.4 82.1 81.6 78.2 80.6

Total 2738 2975 3208 3413 3883 16217

χ2(4) = 23.273, P= 0.001, contingency coefficient = 0.038

Table 3. Good health status by age group.

Age group

Good health status

Young age(15 to 30 years) Middle age (31 to 59 years) Elderly (60+ years)

Total

Poor 10.3 7.4 43.6 19.4

Good 89.7 82.6 56.4 80.6

Total 6283 6973 2961 16217

χ2(2) = 1458.12, P= 0.001, contingency coefficient = 0.287

3.2. Multivariate Analysis

Table 4 presents information on the variables which are

correlated (or non-correlated) with private health insur-

ance coverage in Jamaica of people 15 years and older.

Using logistic regression, twelve variables emerged as

statistically significant determinants of health insurance

coverage in this sample (Table 4). These variables are

social standing (two wealthiest quintiles: OR = 1.68,

95% CI = 1.23 – 2.30), income (OR = 1.00, 95% CI =

1.00 – 1.00), durable goods (OR=1.16, 95% CI = 1.12 –

1.19), marital status (married: OR=1.97, 95% CI = 1.61 –

2.42), area of residence (Peri-urban: OR = 1.45, 95% CI

= 1.199 – 1.749; urban: OR = 1.831, 95% CI = 1.395 –

2.402), education (secondary: OR = 1.57, 95% CI = 1.20

– 2.06; tertiary: OR = 9.03, 95% CI = 6.47 – 12.59), so-

cial support (OR = 0.64, 95% CI = 0.53 – 0.76), crowd-

ing (OR = 1.14, 95% CI = 1.02 – 1.28), psychological

conditions (negative affective: OR = 0.97, 95% CI = 0.94

– 1.00; positive affective: OR = 1.11, 95% CI = 1.06 –

1.16), number of males in household (OR = 0.85, 95%

CI = 0.77 – 0.93), living arrangements (OR = 0.62, 95%

CI = 0.41 – 0.92) and retirement benefits (OR = 1.55,

95% CI = 1.03 – 2.35).

The model [Eq. 4] had statistically significant predic-

tive power (model χ2 = 1604.389, P = 0.001; Hosmer and

Lemeshow goodness of fit χ2 = 5.280, P = 0.727), and

correctly classified 91.3% of the sample (Correct classi-

fication of cases of reported health insurance coverage =

32.0% and correct classification of cases with no insur-

ance coverage = 98.3%).

4. DISCUSSION

This study found that health insurance coverage is influ-

enced by social standing, durable goods, income, marital

status, area of residence, education, social support,

crowding, psychological conditions, retirement benefits,

living arrangements and the number of males in the

household, and that those with good health are more

likely to purchase health insurance than those with poor

health. Continuing, rural residents, elderly and poorest,

are the least likely to purchase health insurance coverage

in Jamaica.

In the literature, it is well documented that the major-

ity of uninsured workers in South Dakota were either

employed or self-employed [6]. The poor, elderly and

many rural residents are more likely to be employed on a

seasonal basis in the informal sector, and these occupa-

tions and employment types do not have private health

insurance, suggesting a further rationale for why unem-

ployed people within a particular socio-economic status

would be less likely to be holders of health insurance

coverage. In this study, it was revealed that more unin-

sured Jamaicans were poor, elderly and from rural zones,

and these were the ones most likely to be unemployed in

Jamaica. The current study was not able to validate the

direct claim of employability of the uninsured, but the

elderly can indirectly validate the literature that more

unemployed people do not have health insurance. In ad-

dition to the aforementioned fact, another finding was

that poor health is associated with low income, owing to

P. A. Bourne et al. / HEALTH 2 (2010) 541-550

547

Table 4. Logistic regression: Private health insurance coverage by some variables.

95.0% C.I.

P Odds Ratio

Lower Upper

Age 0.443 1.00 0.99 1.00

Middle quintile 0.174 1.24 0.91 1.71

Two wealthiest quintiles 0.001 1.68 1.23 2.30

†Poorest 20%-to-poor 1.00

Household Head 0.213 1.80 0.71 4.55

Logged medical expenditure 0.671 1.01 0.95 1.08

Average income 0.009 1.00 1.00 1.00

Durable goods 0.000 1.16 1.12 1.19

Separated or Divorced 0.608 0.90 0.61 1.33

Married 0.000 1.97 1.61 2.42

†Never married 1.00

Peri-urban 0.000 1.45 1.10 1.75

Urban 0.000 1.83 1.40 2.40

†Rural area 1.00

Environment 0.116 0.85 0.70 1.04

House tenure - rented 0.999 0.00 0.00

House tenure - owned 0.950 1.04 0.27 4.03

House tenure - squatted* 1.00

Secondary 0.001 1.57 1.20 2.06

Tertiary 0.000 9.03 6.47 12.59

†Primary and below 1.00

Social support 0.000 0.64 0.53 0.76

Sex 0.722 1.03 0.86 1.24

Crowding 0.018 1.14 1.02 1.28

Crime index 0.652 1.00 0.99 1.01

Land ownership 0.665 0.96 0.79 1.16

Negative affective 0.034 0.97 0.94 1.00

Positive affective 0.000 1.11 1.06 1.16

Number of males in house 0.001 0.85 0.77 0.93

Number of females in house 0.622 0.98 0.89 1.07

Number of children in house 0.438 0.97 0.90 1.05

Living arrangement 0.017 0.62 0.41 0.92

Retirement benefits (1 = yes) 0.038 1.55 1.03 2.35

Poor health status 0.309 0.94 0.83 1.06

-2Log Likelihood = 3982.175

Nagelkerke R Square = 0.359

Model χ2(8) = 1604.389, P-value =0.001

Hosmer and Lemeshow χ2 = 5.280, P = 0.727

Overall correct classification = 91.3%: Correct classification of cases of reported health insurance coverage = 32.0%; Correct classification of cases

with no health insurance coverage = 98.3%

†Reference group

P. A. Bourne et al. / HEALTH 2 (2010) 541-550

548

the difficulties it creates with accessing crucial health

care [6].

This research disagrees with the literature that the

poor have lower health statuses, suggesting that they

have more health-related conditions than the wealthy.

The rich engage in highly involved particular lifestyle

practices that expose them to health hazards, and this is

not equally comparable to the poor environment of the

poor, justifying why they reported the least health status.

Pacione [10] has shown that the quality of the physical

environment affects the quality of life (or health or

wellbeing) of people, but that lifestyle behavioural prac-

tices play a significant role in determining one’s health

[11] like the physical milieu. [12,13] Moreover, the high

cost of health care is a deterrent for the poor to have

health insurance coverage; [6] and we concur with the

literature as we found a positive statistical association

between self-rated health insurance coverage and income.

However, in this study we have refined the income vari-

able, as there is a ceiling to income and its relation with

the purchase of health coverage in Jamaica. The current

work has revealed that those in the wealthy-to-wealthiest

quintiles were twice as likely to purchase health insur-

ance coverage as the poor-to-poorest people. Within the

context that those in the wealthiest quintile purchased

the most health insurance and indicated the lowest health

status, it can be inferred that the purchase of health in-

surance is in keeping with their life style and the per-

ceived role of income in buying good health, as against

preventative behaviour.

Health insurance coverage is an elderly phenomenon,

[6] and this work does not concur with the literature. The

argument put forward is that younger people are health-

ier, and so do not see the need to invest in health cover-

age, as the risk of becoming ill is low, hence the will-

ingness to engage in risky behaviour compared to their

older counterparts, [6] suggesting that the futuristic end

for health insurance coverage becomes even more criti-

cal after 30 years when more people will have families,

as well as the fact that the purchase of health insurance

may materialize owing to futuristic changes in the eco-

nomic circumstances of the individual.

There is a statistical relationship between socioeco-

nomic conditions and the health status of Barbadians,

which is not the case in Jamaica. A study by Hambleton

et al., [11] of elderly Barbadians revealed that 5.2% of

the variation in reported health status was explained by

the traditional determinants of health. Furthermore,

when this was controlled for current experiences, the

percentage fell to 3.2% (a drop of 2%). When the current

set of socioeconomic conditions was used, they ac-

counted for some 4.1% of the variation in health status,

while 7.1% were due to lifestyle practices compared to

33.5% which were as a result of current diseases. [11]

Despite this fact, it is obvious from the data that there

are other indicators which explain health status; people

do not necessarily pay attention to this fact although they

may have more income or access to more economic re-

sources. This explains the rationale for more health con-

ditions being reported by the wealthiest as well as the

group that purchased the most health insurance, where

the thinking is that money can buy health.

A study published in the Caribbean Food and Nutri-

tion Institute on the elderly in the Caribbean found that

70% of individuals who were patients within different

typologies of health services were senior citizens. [14-16]

Among the many issues that the research reported on are

the five major causes of morbidity and mortality, taken

from the Caribbean Epidemiology Centre, which are of

paramount importance to this discussion, and their in-

fluence on the elderly—cerebrovascular, cardiovascular,

neoplasm, diabetes, hypertension and acute respiratory

infection—and these dysfunctions are highly costly to

treat. It should be noted that many of these dysfunctions

are owing to lifestyle behaviour. Hence, the purchase of

private health insurance coverage by these people when

they become old and approach retirement is in keeping

with the cost of health care and the high likelihood of

becoming ill.

Eldemire, [17] on the other hand, opined that the eld-

erly are not as sick as some people are making them out

to be–“The majority of Jamaican older persons are

physically and mentally well and living in family units”

[17]; but the fact is they are preparing for the eventuality

of health conditions owing to the principle of the degen-

eration of the body with the onset of old age. Eldemire

is somewhat right. The current study found that for every

1 young adult who reported poor health, there were ap-

proximately 2 middle aged adults and 4 elderly persons.

Simply put, there were elderly people with poorer health

than other age cohorts; but of the elderly, more of them

indicated good health status (56.4%). The mere fact of

living longer (life expectancy post retirement is at least

15 years), suggests that the aged population will require

more for medical care if they become ill. [18] With age-

ing the issue is not if they become ill but when. A

group of scholars found that there is a direct association

between ageing and health conditions, [19] a concept

with which this study concurs. And this provides the

explanation for the purchase of private health insurance

more than other age cohorts, because they are at a dif-

ferent stage from other age cohorts in a population.

Health conditions are crucial to the purchase of pri-

mary health insurance coverage, and this is highlighted

by ageing. Eldemire’s works [17,18] have shown that

ageing in an individual does not translate to high physi-

P. A. Bourne et al. / HEALTH 2 (2010) 541-550

549

cal impairments, but that with ageing come particular

changes in the profile of dysfunctions–Alzheimer’s dis-

ease, dementia, cerebrovascular, cardiovascular, neo-

plasm, diabetes, hypertension and acute respiratory in-

fection. [20] A study conducted by Costa [21], using

secondary data drawn from the records of the Union

Army (UA) pension programme that covered some 85%

of all UA, shows that there is an association between

chronic conditions and functional limitation–which in-

cludes difficulty walking and bending, blindness in at

least one eye and deafness [21]. Among the significant

findings is–(i) the predictability between congestive

heart failure in men and functional limitation (i.e. walk-

ing and bending). Although Costa’s study was on men,

this applies equally to women, as biological ageing re-

duces physical functioning, and so any chronic ailment

will only further add to the difficulties of movement of

the aged, be it man or woman. One study has contra-

dicted the works of Eldemire, and it showed that a large

percentage of the elderly suffer from at least one health

condition.

Women are more involved in health seeking behaviour,

compared to their male counterparts, [22] irrespective of

the age factor, and this is owing to the cultural back-

ground in which they live. Unlike women, across the

world men have a reluctance to ‘seek health-care’ com-

pared to their female counterparts. It follows in truth that

women have bought themselves additional years in their

younger years, and it is a practice that they continue

throughout their lifetime which makes the gap in age

differential what it is–approximately a 4-year differential

in Jamaica. In keeping with the preventative care ap-

proach to health care, it would be expected that women

would purchase more health insurance coverage than

them, but this is not the case in Jamaica as gender was

not a predictor of health status. However, the more men

in a household, the less an individual will purchase

health insurance coverage.

The Planning Institute of Jamaica in collaboration

with the Statistical Institute of Jamaica has shown that

while the general health status is commendable, chronic

illnesses are undoubtedly eroding the quality of life en-

joyed by people who are 65 years and older [23,24]. The

JSLC report reveals that the prevalence of recurrent

(chronic) diseases is highest among individuals 65 years

and over. [23] The findings show that in 2000, the

prevalence of self-reported illness/injury for people aged

65 years and over was 41.7%, for those 60 to 64 years it

was 27.6% compared to 19.8% for children less than

five years old. However, the prevalence of self-reported

illness/injury for those 50 to 59 years was 18.8%. Some

36.6% of individuals 65 years and over reported inju-

ries/illnesses in 2002 which is a 5.6% reduction in

self-reported prevalence of illnesses/injuries over 2000,

but the self-reported prevalence of illness/injuries rose

by 25.8% to 62.4% in 2004. [25,26] It should be noted

here that this increase in self-reported cases of inju-

ries/ailments does not represent an increase in the inci-

dence of cases, as according to the JSLC for 2004,the

proportion of recurring/chronic cases fell from 49.2% in

2002 to 38.2% in 2004 [26]. In addition, the PIOJ and

STATIN [23] in (JSLC 2000) opined that individuals

60-64 years of age were 1.5 times more likely to report

an injury than children less than five years of age, and

the figure was even higher for those 64 years of age and

older (2.5 times more). In this paper, the findings con-

curred with the literature that health conditions are sig-

nificantly greater; but other issues account for them not

demanding more health insurance coverage than middle

age adults. This is reinforced in the findings that showed

that people who received retirement benefits were ap-

proximately twice as likely to purchase health insurance

coverage as those who did not receive any retirement

benefits. Embedded in this finding is the fact that health

insurance is a matter of affordability and education, and

not illness, which justifies why rural residents had the

lowest health insurance coverage, yet still the poorest

20% good health status was greater than that of those in

the wealthiest 20%. Statistics revealed that poverty in

2007 for the nation was 9.9%, and rural poverty was

15.3% compared to 4% in peri-urban and 6.2% in urban

areas [27], accounting for the lowest private health in-

surance coverage in that group.

5. CONCLUSIONS

In summary, married Jamaicans are more likely to pur-

chase health insurance coverage compared to those who

were never married, with urban residents being more

likely to purchase health insurance than rural dwellers.

An individual who has attained tertiary level education

was more likely to purchase health insurance than one

with at most primary level education, and those who

lived alone were less likely to purchase health insurance

coverage than those who dwelled with relatives or fam-

ily members. Moreover the wealthiest were more likely

to purchase health insurance, but were less healthy, and

this indicates that income does not buy good health.

Therefore, this study highlighted the need to address

preventative care for the wealthiest, and the fact that

social support is crucial to health care, along with the

fact that medical care costs are borne by the extended

family and other social groups in which the individual is

(or was) a member, which explains the low demand for

health insurance in Jamaica.

P. A. Bourne et al. / HEALTH 2 (2010) 541-550

550

6. DISCLAIMER

The researchers would like to note that while this study

used secondary data from the Jamaica Survey of Living

Conditions, none of the errors in this paper should be

ascribed to the Planning Institute of Jamaica or the Sta-

tistical Institute of Jamaica, but to the researchers.

7. ACKNOWLEDGEMENTS

The author would like to take this opportunity to thank the Data Bank

in Sir Arthur Lewis Institute of Social and Economic Studies, the Uni-

versity of the West Indies, Mona, Jamaica for making the dataset (i.e.

Jamaica Survey of Living Conditions, 2002) available accommodated

the current study.

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