This study presents findings from evaluating, ex ante, the options, implications and feasibility of a major health financing policy change from a largely tax-based to a principles. system following universal national health insurance (NHI) The case country used is Jamaica a small middle-income country faced with contribution-based fiscal and health financing constraints and prodded into the policy choice of persistent NHI in 1996 by recommendations of consultants, international organizations as well as the opportunity provided by its externally funded Health Reform Programme (1997-2005). The approach adopted was to define NHI options by commencing with government's in its 1997 Green Paper on NH! as the baseline; ascertaining from local proposals stakeholderstheir recommendationsfor an NHI plan and eliciting lessonsand design variables from the international experiencewith NHI-type systemsto derive a prototype. This was followed by financial modelling of likely inflows and outflows in each option; assessmentof their merits and viability using criteria such as population coverage, benefits, risk pooling, equity, efficiency, and size of contributions by government; and ranking of scoresto derive a preferred option. workers and As an ex ante analysis (since NHI has not been implemented in Jamaica), the the prototype to be the highest ranked option. It also found that found continuing study macroeconomic difficulties, institutional weaknesses and likely opposition from key stakeholders - factors which affected confidence and derailed the 1997 NHI some proposals for In terms of overall significance, the study highlights international - would still pose major challenges decision makers and planners. ambivalence over design benefit aspects of NHI such as single package and timing of universal coverage. For implementing NHI in Jamaica,it vs. suggestsareas for further research and action such as specifying and phasing benefits; improving aswell asachieving collection systems, quality of health services and targeting stakeholder consensus.