Photo: hdptcar/flickr
Following the previous post, it is important to continue the reflexion about aid to poor countries. At a time when money is short, healthcare in developing countries faces several challenges. If developed countries have health systems organized to answer the problems of the populations, developing countries suffer with poor infrastructures, disorganized systems and funding problems. Ending the fees that people living in poor countries have to pay to get treatment for illnesses would seem to be the right thing to do. However, a review made by experts from the Institute of Tropical Medicine in Antwerp, suggests the switch to free healthcare is not that simple. This review can be read as a supplement to this month's edition of the Oxford University Press Journal: Health Policy and Planning (see link below).
The introduction of user fees to raise financial resources for health and regulate demand for health care in developing countries has been controversial for decades. Promoted since the late 1980s as a way to finance struggling public health facilities in many developing countries, recent years have seen growing criticism of the impact of fees on access to health services, particularly for the most poor and vulnerable groups. The current evidence suggests that their introduction was not beneficial: user fees only raised an average of 5–7% of health sector recurrent expenditures at the national level, net of administrative costs. Additionally, it is not clear that they regulated demand, nor that this is a significant or relevant issue in these contexts. The negative impact of the fees on equity and efficiency has been widely documented, as the review shows.
Having this data in mind, international organizations such as UNICEF and WHO have changed their policy positions on user fees, making efforts to support governemnets in order to eliminate user fees for children and pregnant women, and thus hoping to improve maternal and child mortality outcomes. Many countries, specially in sub-Saharan Africa, have also recently moved away from user fees at the point of delivery for essential health services. This is the critical point, as the review shows: while this policy change has the potential to improve health coverage and access, in particular among the poorest groups, "quick action with no prior preparation can lead to unintended effects, including quality deterioration due to lack of funds, excessive demands on health workers, depletion of drug stocks and ‘crowding out’ of preventive services by curative ones". In order to minimize those unintended effects and make the removal of user fees to be successful, "the policy change must be preceded by careful planning, including supportive policies to address increased service utilization and loss of revenue", the review says.
I must add a new element to this discussion: corruption. It is true that in most of these developing countries corruption is part of the daily life and it is common to see hospital doctors to demand payment from their patients. The drugs are also expensive and patients should have money to pay them as well as some surgical material the procedures they need will demand. Finally, the very long waits also play a role in strategies to demand bribes, specially if an intervention cannot wait that much.
Donors will always be important, specially in countries facing so many social and economic problems, and it is crucial they don't pull out. Countries that decide to abolish user fees need help and financial support: proper government funding and well planned systems for supplying the clinics with drugs and staff are just a good beginning in this road towards better healthcare.
The introduction of user fees to raise financial resources for health and regulate demand for health care in developing countries has been controversial for decades. Promoted since the late 1980s as a way to finance struggling public health facilities in many developing countries, recent years have seen growing criticism of the impact of fees on access to health services, particularly for the most poor and vulnerable groups. The current evidence suggests that their introduction was not beneficial: user fees only raised an average of 5–7% of health sector recurrent expenditures at the national level, net of administrative costs. Additionally, it is not clear that they regulated demand, nor that this is a significant or relevant issue in these contexts. The negative impact of the fees on equity and efficiency has been widely documented, as the review shows.
Having this data in mind, international organizations such as UNICEF and WHO have changed their policy positions on user fees, making efforts to support governemnets in order to eliminate user fees for children and pregnant women, and thus hoping to improve maternal and child mortality outcomes. Many countries, specially in sub-Saharan Africa, have also recently moved away from user fees at the point of delivery for essential health services. This is the critical point, as the review shows: while this policy change has the potential to improve health coverage and access, in particular among the poorest groups, "quick action with no prior preparation can lead to unintended effects, including quality deterioration due to lack of funds, excessive demands on health workers, depletion of drug stocks and ‘crowding out’ of preventive services by curative ones". In order to minimize those unintended effects and make the removal of user fees to be successful, "the policy change must be preceded by careful planning, including supportive policies to address increased service utilization and loss of revenue", the review says.
I must add a new element to this discussion: corruption. It is true that in most of these developing countries corruption is part of the daily life and it is common to see hospital doctors to demand payment from their patients. The drugs are also expensive and patients should have money to pay them as well as some surgical material the procedures they need will demand. Finally, the very long waits also play a role in strategies to demand bribes, specially if an intervention cannot wait that much.
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