User fees: A necessary evil?
Jienchi Dorward explores the perplexing issue of user fees
Empty beds (in Bolivia) because the patients can’t afford them“
Please, he’s an itinerant worker, his family is in the city and he can’t pay for the transport to get home, let alone this treatment.” Yet another patient unable to afford the care that they needed - a common scenario during my elective in Bolivia. I look at the doctor, who shrugs his shoulders. “Somebody has to pay,” he says.Standing in front of this sick young man, who owed less than I spend on an average night out, it seemed obvious that it shouldn’t be him. However, user fees such as this, where patients have to pay for drugs or treatment up front, are widespread in low income areas. Instead of being a problem, many in the global health field have argued that user fees are part of the solution when providing healthcare for the poor.
In the 1980-90s many low-income countries, encouraged by the World Bank, (1) started charging people for drugs and services at government health facilities. Supporters argued that these user fees would generate much needed revenue for health systems weakened by economic difficulties, as well as improving quality and efficiency. (1) However, there was little evidence for these policies and critics quickly pointed out their potentially catastrophic effects on the poor. (2)As these changes were introduced, more evidence emerged to fuel the debate. Some studies showed an increase in use and quality of services after the introduction of user fees. (3) (4) In Cambodia, user fees replaced informal charges, meaning that patients’ money was reinvested into the healthcare system for the benefit of all, rather than vanishing into healthcare workers’ pockets. Quality improved, and so more people used the service, generating more revenue which could be re-invested in a cycle of positive re-enforcement. (4)
Competition with private healthcare services was also intended to improve quality. As government health services depended more on user fees for their income, it would be in their interest to attract more patients by making their services better value for money. However, critics argued that this would encourage staff to improve the quality of income generating, high visibility services, whilst ignoring more cost effective preventative measures like vaccinations.
Evidence also emerged which highlighted the negative effects of user fees on the poor, who often struggle to pay for the treatment they need. In one example from a poor rural district in Kenya, the introduction of user fees led to a drop in the use of services. (5) Exemptions, where certain groups are not expected to pay, were supposed to protect the poor and vulnerable. However, even though children under five and the extremely poor were exempted from newly introduced charges, the use of services amongst these groups dropped as well. (5) This highlighted some of the problems with exemptions; they stigmatise people, they increase administrative costs through the added bureaucracy of assessing who is eligible, and they have to be well publicised to prevent exempted people being deterred by fees they don’t need to pay.
As well as excluding the poor, user fees can also contribute to poverty. Firstly, they force people to redirect their resources to health care, meaning they may not have money to buy seed for their next harvest or to send their children to school. Having to pay large amounts at short notice can force people to sell valuable assets or borrow at high interest rates, often driving them into poverty. Also, by preventing people from accessing healthcare, user fees can keep people in a state of ill health, thereby decreasing their ability to work productively and participate in society.
Another argument used to justify user fees is that they increase efficiency by discouraging ‘frivolous’ use of health services. However, many poor people live in rural areas and have to use large percentages of their income on transport costs to get to health services, making ‘frivolous’ use unlikely. (6) The extra revenue generated by user fees has also proved elusive, with evidence showing that in Africa they only provide 5% of government health expenditure. (6) Many governments and international institutions (including the World Bank) now acknowledge the difficulties in implementing user fees and their potential harmful effects on the poor, with several countries (e.g. Uganda, Zambia) removing them altogether. (6)
This has also required careful thought. Sudden, poorly planned changes can wreak havoc on a health system, (7) as increased demand and a potential decrease in revenue can over-run health facilities with more work than they can manage. Instead of simply removing user fees, alternative systems of funding can be put in place. (8) National social insurance schemes, which are widely used in high-income countries, are funded by contributions from employers and employees.
However, in low-income countries many people are not formally employed and are therefore excluded from the health system. In these situations, smaller scale community insurance schemes may be better. Here members regularly pay a small fee to have their future health costs covered. Yet good evidence showing the effects of these schemes on use and quality of services is scarce. (9) In the case of Uganda, extra funding for health from central government was used to replace lost revenue and cope with the increased number of patients when user fees were removed. (10) However, relatively better off people, who live nearer health services and are better able to access care may benefit more from this than the poor who need care the most. In Cambodia, the trend has been to maintain user fees and complement them with equity funds, where resources are set aside to pay for exemptions for poor people, as well as helping them to access care and pay for transport costs. (10)
Innovative solutions like the example from Cambodia demonstrate that the global health community must move beyond a polarized debate ‘for or against’ user fees. Instead, the cultural and political context of the different alternatives for funding healthcare must be better investigated and understood. Economic and health inequalities, as well as social values such as how much one social group should subsidise another group’s healthcare, are different across the world, and must be considered when making health policy.
In Bolivia, our patient was eventually able to pay after his community got together to raise funds. Global policy makers, donors and governments must do the same and work together to learn from local and global evidence and find innovative ways to ensure that we all get the healthcare we need.
Jienchi Dorward
5th year medical student
University of Bristol
Bristol
jienchino@googlemail.com
(1)Akin J, Birdsall N, Ferranti D, (1987). Financing health services in developing countries: an agenda for reform. Washington, DC: World Bank.
(2) Creese A, (1991). User charges for health care: a review of recent experience. Health Policy Plan; 6:309-19.
(3) Akashi H, Yamada T, Huot E, Kanal K, Sugimoto T, (2004). User fees at a public hospital in Cambodia: effects on hospital performance and provider attitudes. Soc Sci Med; 58:553-64
(4) Litvack J, Bodart C, (1993). User fees plus quality equals improved access to health care: results of a field experiment in Cameroon. Soc Sci Med; 37: 369-83.
(5) Mbugua J, Bloom G, Segall M, (1995). Impact of user charges on vulnerable groups: the case of Kibwezi in rural Kenya. Soc Sci Med; 41: 829-35.
(6) Brikci N, Philips M, (2007). User fees or equity funds in low-income countries. Lancet; 369:10-1.
(7) IRIN News (2006). BURUNDI: Side effects of free maternal, child healthcare http://www.irinnews.org/report.aspx?reportid=59267
(8) Gilson L, McIntyre D, (2005). Removing user fees for primary care in Africa: the need for careful action. BMJ; 331:762-5.
(9) Palmer N, Mueller DH, Gilson L, Mills A, Haines A. (2004). Health financing to promote access in low income settings-how much do we know? Lancet; 364:1365-70.
(10)Meessen B, Van Damme W, Tashobya CK, Tibouti A, (2006). Poverty and user fees for public health care in low-income countries: lessons from Uganda and Cambodia. Lancet; 368:2253-7.
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