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AFRO-NETS> Food for a fair thought (2)

  • Subject: AFRO-NETS> Food for a fair thought (2)
  • From: Claudio Schuftan <aviva@netnam.vn>
  • Date: Thu, 9 Jan 2003 01:33:13 -0500 (EST)

Food for a fair thought (2)


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].

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.

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:

1. 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 per-
centage of income and the employer pays a part of the premium). Inno-
vative 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 it. [Note that a mixed system of fees and insurance is
also possible].

2. If a fee for service system is chosen, under-five care, maternal
services, preventive care, chronic diseases treatment, mental health
and STD/AIDS/epidemic diseases services should remain free of charge.
The option also exists to exempt all payments at the most peripheral
rural facilities 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 pay less rather than less 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 are not so for the poor!].

3. A system for certifying indigency needs to be determined before
launching a 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.

4. A cost-sharing system cannot be piloted; it has to start nation-
wide from the beginning. It thus requires substantial pre-planning.

5. Collection of fees at the peripheral level brings with it security
problems (safeguarding the money) for health care personnel collect-
ing it: ad-hoc measures must be taken.

6. Accounting/auditing systems need to be set up prior to launch so
that the administrative personnel needs to be trained accordingly.

7. Payments for inpatient services need to be capped for the poor,
e.g., maximum five days charged.

8. Referrals to higher levels of care also have to be capped so as
not to penalize the sicker.

9. Cost-sharing on laboratory, X-ray services and on some 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.

10. Assessing the ability to pay of users has to precede even the
planning of cost-sharing interventions.

11. Assessing the users/payers socio-economic and other characteris-
tics before and after launching is also a must.

12. 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).

13. 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 recom-
mended. (If patients have to pay, they may choose these over public
providers now charging).

14. 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-

15. Fee revenues are best used approximately using the following for-
mula (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 prov-
ince). [In case of unacceptably low staff salaries, 20% of revenue
can be considered for use for topping up salaries].

16. Studies are needed to assess users' perceived quality of care
shortcomings in government facilities so as to concentrate expendi-
tures on closing these gaps first.

17. District health management teams (or equivalent), with community
participation, have to have control over expenditures of fee reve-
nues. 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.

18. 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%

Claudio Schuftan
Ho Chi Minh City, Vietnam

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