An Economic and Policy Analysis

Janiel McEwan, Economist and Researcher

On any given Tuesday morning, the corridors outside the imaging departments of Jamaica's public hospitals tell a quiet story of deferred care. A pensioner from Above Rocks waits eleven weeks for an MRI to confirm whether the pain in her hip is arthritis or something more serious. A mother in Spanish Town is told her daughter's mammogram will not be available for two months, a delay that, in oncology, can mean the difference between a treatable stage and an advanced one. A construction worker in Portmore carries a referral slip for a CT scan that his doctor wrote six weeks ago, still waiting for a slot to open.

These are not isolated grievances. They are symptoms of a structural problem that has quietly built up inside Jamaica's public health system for more than a decade: too few diagnostic machines, too little money to keep the ones that exist running, and a population whose medical needs are growing faster than the state's capacity to meet them.

It was against this backdrop that Health Minister Dr Christopher Tufton, speaking at the inauguration of the Oasis Imaging and MRI Centre's Half Way Tree branch, made an argument that will shape Jamaican health policy for years to come. Government, he said, cannot carry the financing of a modern health system alone. Sustainability, in his telling, depends on deeper partnership between the public purse and private capital, particularly in diagnostic imaging, where machines are costly to buy and expensive to maintain, and where private operators already hold capacity the state could rent rather than replicate. He pointed to the new facility's use of artificial intelligence in diagnostic support as evidence of where the frontier is moving, and he pushed back on the suggestion that government is simply incapable of meeting scan demand, framing the challenge instead as one of maintenance and asset management rather than willpower.

It is a claim that deserves more than a nod of agreement or a reflexive cry of privatisation. The question it raises sits at the heart of development economics: when a government's fiscal space is genuinely constrained, does inviting private capital into essential services expand access for everyone, or does it quietly create two health systems wearing one flag, one fast and well-equipped for those who can pay a premium, the other slow and undercapitalised for those who cannot? This is the question this analysis sets out to answer, testing Dr Tufton's claims against economic theory, comparative international evidence, and the specific fiscal and demographic realities Jamaica now faces.

Understanding Tufton's Argument

Strip away the politics and the minister's position rests on a small number of economic premises, each defensible on its own terms.

The first is that government resources are finite, a truism worth repeating in a small, debt-constrained economy. The second is that imaging equipment, MRI and CT scanners especially, carries extraordinarily high capital cost, often running into the millions of US dollars per unit before installation and retrofitting are even considered. The third is that the ongoing burden, maintenance, licensing, imported parts, and specialist servicing, frequently exceeds the original price over the machine's life. The fourth is that private operators already possess meaningful excess capacity the state could access through service contracts rather than building parallel infrastructure. The fifth is that such partnerships could shrink waiting lists at a fraction of the cost of new capital works. The sixth folds in artificial intelligence, positioning AI-assisted diagnostics as a productivity multiplier the public system could access through purchase agreements. The seventh, and perhaps most significant, is that government should buy services where it makes economic sense, rather than duplicate infrastructure a competent private provider already operates.

Economists will recognise this as a conventional make-or-buy argument, the logic that governs decisions inside any large organisation about which functions to build in-house and which to contract out. Where a private market already has spare, well-maintained capacity, purchasing the service usually dominates building a duplicate asset. The appeal is not ideological; it is a straightforward application of comparative advantage to a sector where capital is scarce. That, however, is where the easy part ends. Healthcare is not a generic service market, and applying make-or-buy logic without qualification risks importing assumptions that do not hold.

The Economics of Healthcare

Economists have long treated healthcare as an unusually difficult sector to leave entirely to markets, and the reasons are worth setting out plainly before assessing any partnership model.

Healthcare is best understood not as a pure public good, which would be non-excludable and non-rival like national defence, but as a merit good, a service society deems so valuable that it wants to guarantee access regardless of a person's ability to pay, even though it is technically possible to exclude non-payers from receiving it. This distinction matters because it explains why virtually every advanced economy intervenes heavily in health markets rather than leaving them to price signals alone.

The reasons for intervention cluster around several classic market failures. Information asymmetry sits at the centre: patients rarely have the clinical knowledge to judge whether a recommended scan or procedure is necessary, giving providers scope to induce demand that serves revenue more than health. Moral hazard follows, since once a patient is shielded from the marginal cost of care, both patients and providers have weaker incentives to economise. Adverse selection compounds the problem on the insurance side, as insurers who cannot fully observe risk attract disproportionately unhealthy customers, pushing premiums upward. Externalities matter too, most visibly in vaccination, where an individual's decision to seek or avoid care carries consequences others do not fully bear.

Beneath all this lies the perennial tension between equity and efficiency. A pure market allocates scans to whoever values them most in monetary terms, not whoever needs them most urgently on clinical grounds. Cost-benefit analysis in health economics weighs quality-adjusted life years and productivity losses against fiscal cost, while opportunity cost reminds policymakers that every dollar spent on one diagnostic pathway is unavailable for primary care or debt service. Fiscal sustainability closes the loop: a system that promises universal access but underfunds it accumulates an invisible liability, deferred maintenance and rationing by waiting list, that eventually surfaces as crisis.

Taken together, these features explain why health markets rarely self-correct toward efficient, equitable outcomes without deliberate government intervention, whether through direct provision, regulation, subsidy, or, as Dr Tufton proposes, carefully structured partnership.

Jamaica's Healthcare Financing Challenge

Jamaica's fiscal starting point makes this debate more urgent than in wealthier peer economies. Public expenditure on health has hovered around 5% of GDP in recent years, a share that has remained broadly stagnant even as demand pressures intensify. Government health spending accounts for only a modest share of total public expenditure, and a meaningful portion of the country's overall health bill is still paid out of pocket by households at the point of use, a pattern that itself signals gaps in public provision.

Layered on top of this constrained envelope is an unmistakable epidemiological shift. Jamaica's disease burden has moved decisively toward non-communicable conditions. Recent national survey data put the prevalence of hypertension among adults at roughly a third of the population, with diabetes affecting more than one in ten adults, and both conditions rising steeply with age, exceeding seventy percent for hypertension among those over sixty-five. Public health authorities have separately estimated that roughly 54% of Jamaicans are overweight or obese, one in three lives with hypertension, and about eighty percent of all deaths in the country are attributable to non-communicable disease. These are precisely the conditions that generate sustained demand for diagnostic imaging: cardiac scans for hypertensive patients, renal and vascular imaging for diabetics, and cancer screening for an ageing population in which cancer incidence rises with every additional decade of life.

As the population ages, chronic disease management shifts from episodic treatment to long-term surveillance, precisely the kind of care that relies on repeated imaging rather than one-off intervention. Medical inflation, driven by imported equipment, foreign-currency consumables, and global shortages of radiologists and biomedical technicians, tends to outpace general inflation, eroding the purchasing power of a health budget that is not growing in real terms.

Jamaica's fiscal space to absorb these pressures is further limited by the legacy of debt servicing. Although the country's debt-to-GDP ratio has fallen substantially from its post-2010 peak through a sustained and genuinely impressive fiscal consolidation, government debt still stood at roughly 68% of GDP as of 2024, and debt service continues to compete with health, education, and infrastructure for a limited pool of recurrent revenue. In this context, the argument that government cannot simply spend its way to a fully modernised diagnostic fleet is not a rhetorical flourish. It is close to a fiscal fact. The more interesting question is what follows from that fact.

Medical Imaging: Why It Has Become So Expensive

To understand why imaging has become the flashpoint of this debate, it helps to look inside the economics of the machines themselves. MRI scanners require liquid helium cooling, shielded rooms, and specialised electrical infrastructure before a single patient is scanned. CT scanners carry lower upfront costs but still demand precise calibration and radiation-safety compliance. PET scanners, used for oncological and cardiac assessment, add the further complexity of on-site radiopharmaceutical production, since the isotopes decay within hours. Ultrasound and mammography units are comparatively affordable, but mammography still requires stringent periodic recalibration, while cardiac imaging often bundles multiple modalities, multiplying both capital and servicing costs.

The purchase price is often the smaller part of the total cost of ownership. Maintenance contracts with manufacturers can run into six figures annually per machine, and departing from them in favour of cheaper third-party servicing frequently voids warranties. Software licensing has become a growing cost centre as scanners increasingly depend on manufacturer-controlled updates, effectively locking purchasers into subscription-like payments. Replacement parts are almost invariably imported, exposing total ownership cost to exchange-rate risk and shipping delays that can leave a machine offline for weeks.

Perhaps the least visible but most consequential cost is human capital. Jamaica, like much of the developing world, faces a persistent shortage of radiologists and biomedical engineers qualified to service sophisticated equipment. When a machine breaks down and the only qualified technician is overseas or booked months out, downtime translates directly into a longer public waiting list, regardless of how many scanners government has purchased. This is precisely the maintenance problem Dr Tufton pointed to, and it is a genuine one. Many developing economies discover, expensively, that acquiring diagnostic equipment is the easy half of the challenge; sustaining it over a ten-year asset life is the harder half.

Public-Private Partnerships: What Does the Evidence Say?

Given how live this issue has been internationally, Jamaica does not have to guess how health PPPs perform. It can look at a substantial and sobering body of evidence.

The United Kingdom's Private Finance Initiative, under which private consortia financed, built, and operated NHS hospitals in exchange for decades-long repayment contracts, is perhaps the most heavily studied cautionary example. Parliamentary inquiry found that roughly 31% of PFI projects were delivered late and 35% ran over budget, undermining the central promise that private discipline would outperform public procurement. Independent economic analysis went further, arguing that the private cost of capital under PFI was consistently and substantially higher than government borrowing, without commensurate evidence of offsetting efficiency gains, and that the risk supposedly transferred to private investors was often concentrated in the construction phase, leaving virtually guaranteed income during the far longer operational phase. The practical consequence for several NHS trusts was that debt-service obligations to their PFI financiers ended up crowding out clinical staffing and bed capacity, precisely the opposite of what the policy was meant to achieve. This does not mean PPPs are inherently flawed. It means that poorly structured risk allocation and weak contract discipline can turn a partnership into a long-term fiscal liability dressed up as private innovation.

Singapore offers a markedly more encouraging picture, built on a different institutional foundation. Its financing model, the S+3Ms, layers government subsidies, a compulsory personal medical savings scheme called Medisave, catastrophic insurance through MediShield Life, and a means-tested safety net fund called Medifund, atop a delivery system mixing public and private hospitals. The government retains firm control over supply-side capacity and pricing even as private providers deliver much of the care, an arrangement that has produced strong outcomes at modest cost by international standards. The lesson is not that Medisave-style accounts are immediately transplantable, they presuppose a far larger formal-sector wage base, but that partnership works when paired with unusually disciplined public stewardship of financing and pricing.

Costa Rica's Caja Costarricense de Seguro Social is arguably closer to Jamaica's starting conditions. Its EBAIS primary care teams, introduced in 1995, blend payroll-financed public funding with delivery arrangements that, in several regions, rely on private cooperative and NGO management contracts rather than direct civil-service employment. Primary care coverage rose from roughly a quarter of the population to over ninety percent within two decades, with measurable declines in infant and adult mortality. The critical design choice was that private and cooperative partners operate under the same universal entitlement rules as public staff, so partnership expanded access rather than fragmenting it by ability to pay.

Barbados, closer to Jamaica in scale, has moved more cautiously, favouring selective diagnostic partnerships and equipment leasing at the Queen Elizabeth Hospital over large infrastructure PFI, a scepticism born of watching the UK experience unfold. Australia and Canada offer instructive middle cases: Australia through its dual public-private hospital system with regulated insurance rebates, Canada through provincial contracting-out of imaging to private clinics inside its single-payer framework, expanding MRI and CT access while remaining politically contested on queue-jumping grounds.

The synthesis across these cases is fairly clear. PPPs can genuinely expand capacity and improve efficiency, but only where four conditions hold: risk is allocated to whichever party can manage it most cheaply rather than dumped wholesale on the private partner in theory and the public purse in practice; procurement is transparent and genuinely competitive rather than negotiated with a single incumbent; independent regulatory oversight exists to monitor cost, quality, and equity outcomes over the life of the contract; and long-term fiscal liabilities are recognised and budgeted for explicitly rather than treated as off-balance-sheet financing that conveniently avoids showing up in headline debt figures.

AI in Medical Diagnostics

The Oasis Imaging Centre's use of artificial intelligence in diagnostic support, cited approvingly by the minister, deserves its own scrutiny, since AI in radiology has moved from experimental to commercially deployed remarkably quickly.

Modern diagnostic AI typically relies on machine learning models trained on large libraries of labelled medical images to recognise patterns associated with disease, from lung nodules on CT to microcalcifications on mammography that can indicate early-stage breast cancer. In well-validated applications, these systems function as a second reader, flagging areas of concern for a human radiologist to confirm, meaningfully reducing missed findings and speeding up turnaround, both valuable where waiting lists are long. Clinical decision support tools built on similar foundations can also help triage which patients need urgent review, useful where specialist capacity is scarce.

The risks deserve equal weight. Algorithms trained predominantly on data from other populations can perform less reliably on Caribbean patients if training data does not reflect regional demographic diversity, a bias easy to overlook until it produces a missed diagnosis. Regulatory frameworks for medical AI remain immature even in wealthier jurisdictions, raising open questions about liability when an algorithm contributes to error. Cybersecurity is a further concern, since imaging systems increasingly connect to cloud infrastructure storing sensitive patient data, exactly the kind of target Jamaica's public sector has already learned to worry about through prior incidents. Above all, human oversight cannot be optional. AI in diagnostics performs best as a tool that augments a radiologist's judgement, not one that replaces it, and adoption strategy should make that principle a requirement rather than a promise.

Jamaica can adopt AI-assisted diagnostics responsibly by treating governance as a precondition for procurement rather than an afterthought: requiring vendors to disclose training data provenance and validation performance on Caribbean or comparable populations, mandating human sign-off on every AI-flagged result before it reaches a patient, and building AI governance provisions into the Ministry of Health's broader digital health strategy rather than allowing each private facility to set its own standard.

Arguments Supporting Tufton's Position

The strongest case for Dr Tufton's position rests on several genuinely compelling potential benefits. Well-structured service contracts with private imaging providers could shorten waiting times for MRI, CT, and mammography meaningfully within a short timeframe, since the capacity already exists and does not require years of capital works to bring online. Greater access for public patients follows directly, particularly if contracts are structured with equity safeguards that guarantee a defined allocation of public-referred patients rather than leaving access purely to willingness to pay. Reduced capital expenditure frees up scarce public capital budgets for other pressing needs, from primary care infrastructure to rural clinic upgrades. Private operators, competing for both public contracts and private patients, have commercial incentives to keep machines running and well maintained, potentially improving overall asset utilisation compared with underfunded public equipment. Partnership can also facilitate technology transfer and exposure to newer diagnostic modalities and AI tools faster than a purely public procurement cycle typically allows, while shifting the maintenance burden, one of the public system's most persistent operational headaches, onto operators whose core business depends on keeping their machines functioning.

Counterarguments

Against these benefits sit risks Jamaican policymakers cannot responsibly wave away. The most fundamental is a two-tier health system, in which private facilities offer fast, well-equipped care to those who can pay, while the public system, its budget partly redirected to service contracts, continues to struggle for those who cannot. Profit motives, left unchecked, can encourage cream-skimming, private partners competing eagerly for the most profitable, least complex work while leaving costlier cases to the public system. Poorly negotiated contracts, as the UK experience shows starkly, can produce higher long-term costs than direct public provision once financing and decades-long payment obligations are tallied. Weak regulatory capacity, a genuine constraint in a small state, raises the risk of contract failures going undetected until they become expensive crises. Where only one or two credible operators exist in a diagnostic niche, monopoly pricing becomes a real danger once the public system depends on a single provider. Rural access poses its own equity challenge, since private investment naturally clusters in Kingston, Spanish Town, and Montego Bay, leaving rural parishes at continued risk of being underserved. Political patronage in contract award, accountability gaps, and fiscal liabilities that do not appear on the government's headline balance sheet round out a list of risks that is neither hypothetical nor uniquely Jamaican.

International Lessons for Jamaica

Drawing these threads together, several transferable lessons emerge. Singapore's experience suggests that private delivery works best when paired with unusually strong public control over financing architecture and pricing, a governance capability Jamaica would need to build deliberately rather than assume. NHS England's PFI experience is essentially a cautionary tale about risk allocation and off-balance-sheet financing, and Jamaica's Ministry of Finance and Planning would do well to insist that any healthcare PPP liabilities appear transparently in fiscal reporting from the outset. Costa Rica demonstrates that private and cooperative delivery partners can expand equitable access when they operate under the same universal entitlement rules as public providers, rather than a parallel fee-for-service track. Barbados illustrates that a cautious, incremental approach to smaller diagnostic partnerships, rather than large infrastructure-scale PFI, can suit a small island economy without exposing it to the scale of fiscal risk the UK encountered. Chile's experience, having moved between more market-oriented and more state-centred health financing models over several decades, underscores that equity outcomes depend far more on the strength of regulatory and financing design than on the public or private identity of the provider delivering care.

Policy Recommendations

Jamaica does not need to choose between an idealised fully public system it cannot currently afford and an unregulated private expansion that risks entrenching inequality. A carefully governed middle path is available, and it should include several concrete elements.

A National Health PPP Framework, legislated rather than left to ad hoc ministerial agreements, would establish consistent rules for how partnerships are structured and reported. Performance-based contracts, tying payment to verified turnaround times, accuracy audits, and defined public-patient quotas, would replace vague service agreements with measurable obligations. Independent regulatory oversight, housed separately from the Ministry of Health to avoid the conflict of a purchaser auditing itself, would monitor cost, quality, and equity over each contract's life. Transparent, competitive procurement would guard against both patronage risk and the monopoly pricing that emerges when only one credible bidder exists. Investment in digital health records, letting imaging results follow the patient rather than the provider, would reduce duplicate testing. A national diagnostic strategy, mapping public capacity gaps against private concentration, would keep rural parishes from being left behind as investment clusters around Kingston and Montego Bay. Sustained investment in prevention, given how heavily non-communicable disease drives imaging demand, would relieve waiting-list pressure more durably than any number of new scanners. Ring-fenced maintenance funding would address the asset-utilisation problem at the root of the current crisis. AI governance legislation, covering data provenance, human oversight, and liability, should accompany rather than trail adoption of diagnostic AI. Capacity building in radiology and biomedical engineering, alongside workforce retention strategies, would address the human capital constraint no amount of equipment can substitute for. Public reporting requirements, making PPP performance visible to Parliament and citizens alike, would close the accountability loop that so often goes missing once a contract is signed.

Broader Economic Implications

The stakes here extend well beyond hospital waiting rooms. A health system capable of diagnosing and managing chronic disease earlier keeps workers economically productive for longer, directly supporting GDP growth and labour productivity in an economy that, like much of the Caribbean, cannot rely on demographic expansion to drive growth. Reliable, well-regulated healthcare infrastructure also factors into foreign investors' assessments of a country's overall institutional quality, and a credible diagnostic and treatment sector underpins any serious ambition Jamaica has for medical tourism, a niche several Caribbean and Central American peers have pursued with commercial success. Healthier populations translate into stronger human capital formation and better educational outcomes, since children with untreated chronic illness or undiagnosed conditions in the household consistently show weaker school performance. Life expectancy gains and reduced premature mortality feed directly into measures of national competitiveness and into the human development targets embedded in Vision 2030 Jamaica, which explicitly links health system strengthening to the country's broader development trajectory. None of this happens automatically. It happens only if the financing model chosen to close today's imaging gap is judged not merely on how quickly it shortens a waiting list, but on whether it builds a health system resilient enough to sustain those gains for decades.

Conclusion

The debate Dr Tufton has opened is not, at bottom, a contest between government and private healthcare, however easily it might be framed that way in the heat of public commentary. Jamaica already runs a mixed system, and has for decades. The real question is whether the country can design a healthcare architecture that is financially sustainable within its genuine fiscal constraints, technologically current enough to keep pace with a changing disease burden, equitable enough that a patient's postal code and payslip do not determine how quickly a tumour is found, and patient-centred enough that efficiency gains actually translate into shorter waits and better outcomes rather than simply better margins for whoever holds the contract.

International evidence offers neither a blank endorsement nor a blanket condemnation of public-private partnership in health. It offers something more useful: a reasonably clear map of the conditions under which partnership expands access and the conditions under which it quietly entrenches a two-tier system while sending the bill to the next generation of taxpayers. Singapore, Costa Rica, Barbados, and the more sobering example of the NHS all point toward the same governing insight, that the quality of the contract, the strength of the regulator, and the transparency of the financing determine the outcome far more than the ownership structure of the machine itself.

The future of Jamaican healthcare will not, in the end, be decided by who owns the MRI scanner in Half Way Tree. It will be decided by whether every Jamaican, whatever parish they live in and whatever they earn, can get a scan read accurately, promptly, and without a bill that forces an impossible choice between treatment and household survival. That is the standard against which this partnership, and every one that follows it, should be measured.