PHA-Exchange> Food for a fair thought (2)

[Aviva]

SOME PEARLS OF WISDOM ABOUT HEALTH CARE FINANCING (Part 2 of 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 levyed 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 percentage of income and the
employer pays a part of the premium). Innovative 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 nationwide 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 collecting 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, Xray 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 characteristics
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 recommended. (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-negotiable.

15. Fee revenues are best used approximately using the following formula
(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 province). [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 expenditures on
closing these gaps first.

17. District health management teams (or equivalent), with community
participation, have to have control over expenditures of fee revenues. 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% additional.

Claudio Schuftan, Ho Chi Minh City
aviva at netnam.vn