18. SOME PEARLS OF WISDOM ABOUT HEALTH CARE FINANCING.

1. Equity in health means equal access for equal need.
2. Near-zero-priced public services for the poor is an essential public policy towards equity.
3. Government intervention in the inequitable workings of the free market is required to bring about equity in health. The problem of resource shortages in the health sector cannot thus be seen as only a sectoral problem.
4. Health fees are little more than an additional form of direct taxation.
5. Changes in health care financing should be promoted because they will improve the existing situation and not for their own (or the donor’s) sake.
6. Levying fees will prevent the more deprived groups from seeking care at government facilities. It will add an additional barrier to their use. ‘Affordable’ fee levels are next to impossible to set…
7. Even where efforts are made to base fees at affordable levels, the poor will accumulate debt when faced with major illness.
8. Effectively protecting the poor from charges (fees) depends on setting up cumbersome administrative procedures for waving fees.
9. Given that lower socio-economic groups are least likely to use health care services, a sample survey only covering health care users is probably biased toward higher income households.
10. The question that always needs to be kept in mind when interpreting any survey results is: Does willingness to pay reflect ability to pay?… This means that, ultimately, we need to address the ethical issues of the impact of charges on equity.
11. From the World Bank’s perspective, efficiency is the key concern to pursue in health care financing; equity takes second place to efficiency.

The Bank supports a market-based allocation of health resources and envisions a limited role of government in the distribution of societal resources. But ultimately, it is the relative utilization of health resources and facilities by the different socio-economic groups which will tell us about how equitably the allocation of these resources has been. Increasing efficiency is, therefore, not a good enough reason to raise fees.

12. Equity considerations are of primary importance; they are of importance as a policy goal. But the market-based allocation of care discriminates against the poor –with a fee system aggravating this situation.
13. Efficiency considerations are concerned with matters of allocation rather than distribution.
14. The basic justification for assessing equity does not change with the level of resources available in a society: it is the same in rich and poor countries. Moreover, limited resources do not justify greater levels of inequity.
15. With equity in mind, the assessment of the likely impacts of paying fees on users has to be disaggregated by income distribution quintile, and these characteristics of users (and payers) need to be assessed before and after implementing the change.
16. The challenge definitely is finding a just balance between efficiency and equity.
17. From the perspective of the poor, social and economic considerations are too often forgotten in the politics of health care allocations. For instance, treatment costs per event are lower in rural areas, but transport costs for patients are significantly higher. Or, another example to ponder:Seasons determine income and times of low income coincide with times of potentially greatest sickness.
18. Payment exemption mechanisms and retention of revenue arrangements remain grossly unaddressed in health care financing plans….and most of the power still remains centralized.
19. Increasing access to health care is not impossible if fee revenues are retained by the facilities themselves. But barriers still exist for peripheral facilities to retain fee revenues and using them effectively at local level with community inputs.
20. Because public expenditure is more important than taxation in the overall distribution of income, health care expenditures should be biased in favor of the poor. Therefore, need for health care should be defined along the lines of the socio-economic status of households.
21. Income per capita is highly associated with demand for medical care. Low income is a barrier to access to care.
22. Equity has to be understood as a social justice and distributional fairness issue: a more broadly-based socio-economic development is thus a prerequisite for an improved health status that is sustainable.
23. Worldwide, the distribution of health care is already inequitable in socio-economic terms. It will become more inequitable increasing the cost of care. It will reduce the demand for services by the lower income groups and by female household members. It will also delay presentation for care for them. Therefore, raising the cost of treatment will only aggravate poverty.
24. Prices are important determinants of health care demand and that demand is reduced more in response to price changes when income is lower.
25. In summary, health care financing reforms alone cannot bring about sustained better health. The promotion of wider structural changes in society is also required. Health must thus be seen as only a part of total care. Aiming for better universal health care forces us to consider and tackle the unequal distribution of the circumstances under which preventable malnutrition, ill-health and deaths are perpetuated.