PHA-Exchange> Pearls of wisdom on HCF (3)

[Aviva]

From: "gerald moore" <gmoore12 at compuserve.com>

The "pearls of wisdom" were much appreciated and are very
much in line with my own thinking. Some of the principles however are, as
you know,  difficult to implement in practice, for a variety of reasons.

One problem is that in some developing countries the services which should
be provided free, in a fee for service system, often make up the majority
of services provided, eg under-5, maternal and child health, preventive,
chronic diseases, STD/Aids etc. Then there are exemptions for the very
poor. So when one adds all these up, one might find that fees are being
collected from a small proportion of the patient population that is not
enough to make the service financially viable or to plough back enough
funds into improving the system, topping up salaries etc.

Assessing users/payers socio-economic situation and ability to pay is also
difficult (points 10,11), particularly in a rural setting. How does
one really know? In my experience, sometimes the poorest-looking farmer may
have quite a decent income. One possible way is to strengthen the system of
indigent-registration by village chiefs, which is utilized in Ethiopia and
Laos. This enables the poorest in a village to have a card or letter
which guarantees them free health care. ( Point 3).
 Points 14-18 are very important, as is the need to train health workers in
basic planning, accounting, inventory management and budgetary control, a
very high workload in addition to their provision of care and health
educational activities. Do we expect a nurse or medical assistant in a
rural health centre to do too much? Often just caring for the sick and
doing the basic recording paperwork is a full-time job for them, not to
mention looking after finances, accounts and stock control.
To be efficient, any fee for service, cost-sharing or cost-recovery system
would optimally require trained accounting and stores personnel in every
health facility. Even if they could be found and trained, this adds to
personnel and administration costs. However if the system works well, they
could be provided for out of revenue gained.

Point 25 sums up the basic problem in health care very well.

Much to discuss: Each pearl is almost a topic in itself.

Gerald Moore