A question for the Washington UHC Financing Forum: How to finance reduction of out-of-pocket expenses and the end of patient user fees?
By Mit Philips, Médecins Sans Frontières
This week global health leaders and financial experts will gather in Washington to discuss Universal Health Coverage (UHC) and how to finance it. While the Tokyo UHC Conference was buzzing with ambitious declarations about the need to provide every person with access to essential health care without suffering financial hardship, the Washington Forum will need to come up with credible financing plans.
The current discourse pins its hope on mobilisation of domestic resources (DRM), in contrast to the pessimism about additional international funds, inspired by so-called donor fatigue. Note that health funding ‘transition’ ambitions are no longer limited to countries classified as ‘Middle Income’. The pressure from donors — including global health initiatives to shift health expansion plans to domestic funding — is felt in Sierra Leone, DRC, Mozambique, Malawi and other low resource contexts as well.
Reducing unmet targets for DRM (e.g. GDP percentage) to lack of political will seems unhelpful, as factors such as economic volatility and fiscal space restrictions significantly affect real life health improvements. It is also hard to accept a rationale that international investments towards universal health coverage could be withheld from countries failing to meet such targets, punishing precisely those people suffering most from inequitable access to care.
Besides the question of whether DRM can actually yield sufficient funding for health in the medium term, premature ‘transitions’ risk creating more and deeper health gaps instead of progress to better access to care. The dominant use of the ‘sustainability yard’ stick reminds us the human cost of development programs in the nineties, rejecting all but self-sufficient health interventions. This approach, devoid of shared responsibility, de facto froze the potential of effective health interventions and trapped poor countries’ populations in an unhealthy, deadly limbo. The prospect of enabling countries to access more loans for health has raised some enthusiasm, but how to reconcile this with the fact that many of these countries are already heavily indebted?
Moreover, the danger of increasing out-of-pocket expenses is now looming in the prospect of reduced international funds. Lack of precision in the current UHC and DRM terminology may enable increases in household payments for health being labelled as domestic (private) resources.
Out-of-pocket expenses are not only a problem as cause of catastrophic health expenditure. User fees in particular deter demand and distort the entire service delivery system, through exclusion from and delays in care, late alerts of epidemic outbreaks, financial distress and abuse, detention of patients unable to pay, deepening poverty and increasing inefficiencies; all represent a major step backwards from UHC.
While in many low and middle income countries over the past decade transitioned to free healthcare, either for the entire population or for specific groups (e.g. pregnant women, children, and people with certain illnesses), proposals to expand or introduce user fees are currently back on the table. Countries that previously reduced those patient barriers, such as Afghanistan, Mozambique, Malawi and Sierra Leone, now face international health funding cuts and scramble to find alternatives. In other countries with the majority of people living below the poverty line, e.g. Guinea, CAR, Jordan, DRC and Haiti, direct patient payments at the point of delivery of care continue to affect access to care for the most vulnerable, including displaced, patients with HIV, TB, NCDs, and malaria.
In real life this means a.o.: A Malawian mother receives only half of the pills she needs to treat her child, as she is unable to pay the full cost of malaria treatment (equivalent to 9 USD). In the Central African Republic (CAR), a pregnant woman foregoes an HIV test as she cannot afford the equivalent of 2.7 USD. To treat pregnancy complications, she has to pay 1.8 USD per day for IV fluids, forcing her to borrow money and long keep her in debt. A refugee in Jordan cannot afford the fees (23 USD per consultation) for her non-communicable disease (NCD) and stopped treatment. In a rural area of the Democratic Republic of Congo (DRC), a mother and her baby are detained in the hospital until they pay 38 USD for her emergency C-section.
Both WHO and World Bank, leading agencies in UHC, remain disturbingly vague about user fees and the need to eliminate them. Why so little drive for action on the overwhelming evidence of detrimental effects for the population, such as limiting access to care, exacerbating poverty, and “punishing the poor”[1]? And why is there no clear guidance on the fact that user fees will generate insufficient revenues and that individual ‘poverty’ exemptions (i.e. whether a person qualifies as ‘too poor to pay’) are grossly ineffective to protect people from exclusion or financial distress, often with transaction costs exceeding revenues? Also there seems to be a failure to differentiate between high-income countries applying ‘moderation fees’ to curb inappropriate demand and contexts where health care utilisation rates are far below the minimum coverage needed to impact on population’s health.
Without a clear public position and guidance from international agencies such as the World Bank, WHO, Global Fund, GFF and other major donors, consultants and advisors on health financing will conveniently ignore the evidence. Without proactive technical and financial support by international agencies, many national governments will likely fail to uphold their commitments to eliminate user fees and reduce OOP expenses, with negative consequences for all three Universal Health Coverage (UHC) dimensions.
It seems unfortunate that, while international actors are largely supportive of monitoring financial protection in achieving UHC, the financial responsibility to actually reduce or abolish user fees is increasingly seen as that of the government alone, not as a shared responsibility.
In order to translate UHC engagement into improved access and coverage of essential health care, removal of direct patient payments needs to move up higher on the priority action list. Otherwise the harmful practices of ‘Taxing the ill’ will continue and UHC will remain a pipedream — at least for those who need it most.
[1] Statement by Dr Margaret Chan, former WHO General Director, in 2009.
