[afro-nets] Waivers for health services in developing countries

[Claudio Schuftan <claudio@hcmc.netnam.vn>]

Waivers and exemptions for health services in developing coun-
tries
--------------------------------------------------------------

Ricardo Bitrán, Ursula Giedion
October 2002
Paper presented at:
"Protecting the Vulnerable: The Design and Implementation of Ef-
fective Safety Nets"
December 2-13, 2002 - World Bank Institute - Washington, D.C.

Available online as PDF file [97p.] at:
http://www.worldbank.org/wbi/socialsafetynets/courses/dc2002/readings/aldeman.pdf 


".......In response to shortages in public budgets for govern-
ment health services, many developing countries around the
world, have adopted formal or informal systems of user fees for
health care. In most countries user fee proceeds seldom repre-
sent more than 15 percent of total costs in hospitals and health
centers, but they tend to account for a significant share of the
resources required to pay for non-personnel costs.

The problem with user fees is that the lack of provisions to
confer partial or full waivers to the poor often results in in-
equity in access to medical care. The dilemma, then, is how to
make a much needed system of user fees compatible with the goal
of preserving equitable access to services. Different countries
have tried different approaches. Those which have carefully de-
signed and implemented waiver systems (e.g., Thailand and Indo-
nesia) have had much greater success in terms of benefits inci-
dence than countries that have improvised such systems (Ghana,
Kenya, Zimbabwe).

Key to the success of a waiver system is its financing. Systems
that compensate providers for the revenue forgone from granting
exemptions (Thailand, Indonesia, and Cambodia) have been more
successful than those who expect the provider to absorb the cost
of exemptions (Kenya). Where waiver systems exist, performance
will improve with the timeliness of the reimbursement. Other
success factors include the widespread dissemination of informa-
tion among potential beneficiaries about waiver availability and
procedures; the awarding of financial support to poor patients
for non-fee costs of care, such as food and transportation (as
in Cambodia); and the existence of clear criteria for the grant-
ing of waivers, thereby reducing confusion and ambiguity among
those responsible for managing the system and among potential
recipients.

Those facing the task of adopting a system of waivers face mul-
tiple design options. These include the following, among others:
should exemptions be granted to whole groups or on the basis of
individual targeting (the review finds that most systems are
based on the latter)? Should waivers or exemptions be permanent
or temporary? How frequently should eligibility be reassessed?
Should waiver eligibility be determined exante, in the house-
hold, or when individuals seek care in the facility? The review
examines various approaches taken by countries, but assessing
their relative practical merits is difficult, as the evidence is
scattered and mixed......"