The Cost of Free Healthcare
User charges and their effect on compliance
“That’ll be 10 shillings, please.”
I had come to East Africa for my gap year with the rather woolly notion of “helping” the locals and yet here I was taking money off them. But as I ticked off another yellow form, I reflected on how much these Kenyan mothers were getting for their seven pence: monthly visits from the local hospital’s Maternal and Child Health unit, an Oral Polio Vaccine and the three required doses of the Pentavalent vaccine which confers immunity to Hep B, Diptheria, Tetanus, Pertussis (whooping cough) and Haemophilus influenzae type B (HiB, a leading cause of pneumonia) (1). Between them these conditions accounted for over 800,000 deaths every year(2), as well as causing thousands of debilitating and stigmatising deformities. The babies are also weighed to check they are developing at a normal rate. Food parcels are provided if the patients are showing signs of malnourishment and essential vitamins (chiefly retinol – vitamin A – which 127 million pre-school children and 7.2 million pregnant women are deficient in (3)) are given out. Pregnant women can also come for HIV checkups, counselling and testing, and malaria prophylaxis.
What struck me was not just the breadth of the programme but the efficiency of it all. All of the yellow medical records presented were kept by the patients, each was up to date and every mother attended when their children’s immunisations were due. I had seen similar schemes organised by Western NGOs with no charge for users. These had turned into a free-for-all with little organisation and demand (often unnecessary) far outstripping medical supplies. Even the low user charges introduced into the African-run programme gave the nurses time to impress upon the parents the importance of hygiene, diet and adherence to treatment. This system also endowed the patients with a sense of responsibility over their medical records and, by inference, general health.
A decade ago, this was a contentious issue in global health management. However, the international consensus has since turned against charging users for primary healthcare. Critics argue these charges prevent the worlds most needy people from accessing services, encourage reckless prescription and do not recoup costs (4).
What I saw was very different. Whilst they may not finance the entire programme (UNICEF fund the immunisations and USAID pay for the food supplements), the mothers’ 10 shillings covers the rickety minibus which allows the nurses to travel to these remote villages. When patients themselves have to travel, a combination of distance and cost (often more then user fees themselves) reduce attendance significantly (5). Transport can account for more than a quarter of medical bills (6). A personal knowledge of their patients also allows discretion and flexibility in cases of extreme hardship. At times, on the programme I witnessed, eggs were given in lieu of payment, and schemes in Cambodia combine user fees with a ‘health equity fund’ to great effect (7).
From my experience, over-prescribing did not seem evident either. As established above, these fees do little to recoup operational or administrative costs, and when not set within a command-driven economy, they do not make profit for the hospital. In my opinion, without a target-driven quasi-market (a financial incentive to prescribe or vaccinate), the fees are more likely to reduce ‘frivolous demand’ (8) than increase reckless prescription.
The advantages of the project, though, were not limited to increasing efficiency. The practitioners spent time with each mother, instructing them on the proper nourishment of their children, stressing the importance of vaccinations and counselling them to continue regularly taking medication for existing conditions. Antimicrobial resistance is a growing concern for malaria, tuberculosis and HIV, which constitute “a significant proportion of the disease burden in developing countries” (9) and the WHO cites minimising ART (Anti-Retroviral Treatment) interruption as a key to preventing HIV drug resistance (10).
Another criticism levelled against user fees are their tendancy to encourage “use of partial drug doses” (11) but this can be dissuaded with the proper education of sufferers, which the schemes facilitate. Ownership of their yellow forms, together with this extra education and the value imbued to their health services conferred a sense of responsibility to the patients to which they appeared to respond well.
Clearly, this evidence is anecdotal. Nevertheless, a whole plethora of research has been conducted into the efficiency and equity of user charges (4,12) whilst work focusing on the long-term effects of including patients in their treatment plan – such as increasing concordance – is often neglected. If these programmes can help to increase compliance to treatment and successfully reduce drug resistance, the benefits to inter-generational equity would be immeasurable, much more than just a “necessary evil” (13).
These initiatives do not stand alone. They require investment in health education and with this, the elasticity of demand may stretch to paying user fees. If by introducing these policies we can increase efficiency and add value to a service, thereby promoting adherence, then hopefully those ten shillings will be seen as a worthwhile investment.
Isaac Ghinai is a second year medical student at University College London
zaacghinai(at)hotmail.com
References
1. Medical News Today, ‘Pentavalent Vaccine Launched For The First Time In Lesotho’ (from a UNICEF press release), 22/12/2008.
2. P. Chinnock, GAVI Alliance news, ‘Vaccinating against childhoods biggest killer’, 22/06/2009.
3. K. West, American Society for Nutritional Sciences, ‘Extent of Vitamin A deficiency among Preschool children and women of reproductive age’ September 2002.
4. A. Costello, British Medical Journal, ‘Should mother and child health services in developing countries be free?’, 29/03/1997.
5. D. Hodgkin, Health Economics, ‘Household characteristics affecting where mothers deliver in Rural Kenya’, July 1996.
6. N. Brikci and M. Phillips, The Lancet (Vol 369, Issue 9555, pp 10-11) ‘User fees or equity funds in low income countries’, 06/01/2007.
7. W. Hardeman et al., Health Policy Planning, ‘Access to health care for all? User fees plus a health equity fund in Sotnikum, Cambodia’, 2004.
8. C. Griffin, World Bank Paper, ‘User charges for health care in principle and practice’, 1951.
9. Diseases Control Priority Project, ‘Drug Resistance: Disease control is threatened by rise in resistant microbes’, July 2006.
10. D. Bennet et al., Antiviral Therapy (Vol 13), ‘The World Health Organisation’s global strategy for prevention and assessment of HIV drug resistance’, April 2008.
11. L. Gilson, et al., Health Policy, ‘Strategies for promoting equity: experience with community financing in three African countries’. October 2001.
12. L. Gibson, D. McIntyre, British Medical Journal, ‘Removing user fees for primary care in Africa: the need for careful action’. 01/10/2005.
13. B. Meesen et al, The Lancet, ‘Poverty and user fees for public health care in low-income countries: lessons from Uganda and Cambodia’, 23/12/2006.
14. A. Sepehri and R. Chernomas, Journal of International Development (Vol 13, Issue 2, pp183-209), ‘Are user charges efficiency- and equity-enhancing? A critical review of economic literature with particular reference to experience from developing countries’, 11/06/2001.