1. Equality in health means equal access for equal need.
2. Near-zero-priced public services for the very 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 socioeconomic 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, cost-effectiveness 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 socioeconomic 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 in the periphery 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 and equitably 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 socioeconomic 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 deliberate, broadly-based, poor-centered 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 socioeconomic terms. Increasing the cost of care will become more inequitable; 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 costs of treatment will only aggravate poverty.
24. Prices are important determinants of health care demand; the lower the income, the more reduced the demand will be in response to price changes.
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 conditions under which preventable malnutrition, ill-health and deaths are perpetuated.
So what about cost-sharing if a fee for services system is already approved or in place? [Cost-sharing is different from cost-recovery; the former assumes the government still subsidizes costs].
26. The orthodox approach would say: “If health is a right, fees levied on the poor are antithetical and unacceptable”. Nevertheless, when compromises have been made, we first and foremost have to keep up a vigorous advocacy campaign to protest the conditions that have cut government heath care financing to begin with.
27. Additionally, with a fee for service system already a fait-accompli, we have to at least make sure we continue to struggle for certain principles and conditions:
i. Pre-payment schemes are to be preferred over fee for service schemes (and we have to keep pounding on this). The former has more potential for equity (since, in most cases, contributions are a percentage of income and, in the formal sector, the employer pays a part of the premium). Innovative health insurance plans need to be developed though to cover both urban and rural populations – the latter without monthly wages. A growing experience is being reported in the literature; we have to keep up with this literature. [Note that a mixed system of fees and insurance is also possible].
ii. If a fee for service system has been chosen, under-five care, maternal services, preventive care, chronic diseases treatment, mental health and STD/AIDS/epidemic diseases services have to remain free of charge. The option also exists to exempt all payments at the most peripheral rural facilities (i.e., dispensaries) and start charges from district health facilities up. A health card (annual) to be purchased is less cumbersome than a ‘by episode’ payment system. When setting fees, always prefer lower fees – they require less percentage of the population to go through waiver procedures and at the end of the day one ends up with the same revenue (more-people-pay-less rather than less-people-pay-more). A percentage of insurance premia revenues also has to be allocated to PHC/preventive services. [Note that what we think are ‘dirt-cheap’ charges for a service is not so dirt-cheap for the poor!].
iii. A system for certifying indigency needs to be determined before launching any cost-sharing system. It needs to be pre-tested and cannot be too expensive or administratively cumbersome. Waiving systems in which the community has a say are to be insisted upon.
iv. A cost-sharing system cannot be piloted; it has to start nationwide from the beginning. It thus requires substantial pre-planning.
v. Collection of fees at the peripheral level brings with it security problems for health care personnel collecting it (safeguarding the money): ad-hoc security measures must be taken.
vi. Accounting/auditing systems need to be set up prior to launching so that the administrative personnel is trained accordingly.
vii. Payments for inpatient services need to be capped for the poor, e.g., maximum five days charged.
viii. Referrals to higher levels of care also have to be capped so as not to penalize the sicker.
ix. Cost-sharing on laboratory, Xray services and on some expensive essential drugs can be considered in the system. Drugs for chronic diseases, e.g., TB, diabetes, epilepsy should be free for the poor; injections should always be charged.
x. Assessing the ability to pay of users has to precede even the planning of cost-sharing interventions.
xi. Assessing the users/payers socioeconomic and other characteristics before and after launching is also a must.
xii. Assessing the impact of the new system on the demand for services after launching is a must as well. (Of course, this makes a baseline study before launching mandatory).
xiii. Alerting the mission hospitals/clinics (or equivalent not-for-profit and private providers) to expect an increase in demand for services after government facilities begin to charge is highly recommended. (If patients have to pay, they may choose these over public providers now charging).
xiv. Retention of fees by the Ministry of Health (as opposed to the Treasury) is non-negotiable. Within the MOH, retention of fees at the periphery (not necessarily the facility) level is also non-negotiable.
xv. Fee revenues are best used approximately using the following formula (negotiable): 40% to plough back to improve curative services; 40% to allocate to PHC/preventive services; 20% to subsidize poor districts with low revenue to use in PHC (coordinated by the province). [In case of unacceptably low staff salaries, 20% of revenue can be considered for use for topping up salaries].
xvi. Studies are needed to assess users’ perceived quality of care shortcomings in government facilities so as to concentrate expenditures on closing these quality of care gaps first.
xvii. District health management teams (or equivalent), with community participation, have to have control over expenditures of fee revenues. All expenditures have to be budgeted for in an ad-hoc written semi-annual plan (improvisations other than for dire emergencies are not good!). Dispensary staff and community leaders may thus need some training in planning.
xviii. The Treasury (Ministry of Finance) must give assurances to the MOH that no further cuts in the MOH budget will be attempted later when cost-sharing revenue is collected; this revenue is to be 100% additional.
Claudio Schuftan, Ho Chi Minh City,
schuftan@gmail.com