PHA-Exchange> Will the Consumer Benefit?

Fri Jun 6 00:36:56 PDT 2003

The following is one of the articles on Health Care Financing published in Asia Pacific Consumer, No. 30, the quarterly magasine of Consumers International Office for Asia Pacific based in Kuala Lumpur. For more information, visit our website, www.consumersinternational.org/roap

Will the Consumer Benefit? 
AP Consumer, Health Care for All
No. 30 4/2002
By Dr. S. Sothi Rachagan

Many countries are making changes to the manner in which they finance health care. Consumer groups have to ensure that the changes have positive outcomes for consumers. Failure to properly evaluate the proposals may well cause them to be adopted and result in adverse effects that will be costly, if not impossible to reverse at some future date. The following is a set of desired goals that may be used as criteria to evaluate the proposed changes to the health care systems. 

1. Comprehensibility
An important criteria, indeed a pre-requisite to any proposed change, is that it be presented in a manner that the proposal and its major effects can be readily comprehended by consumers.  There are two aspects of comprehensibility that need to be considered:

(a) Are the proposals presented in a manner that the consumer can understand and subsequently intelligently participate in the initial stages of planning, formulation of legislation, and debate which will surround the enactment of the required legislation? The proposals must be clear in terms of the proposed changes, their effects and costs.  Vague terms like "more equity", "contributing to better health", and "expanding options" must be translated into details which are easily understood.

(b) When a proposal is finally implemented, the consumer must be able to understand what rights and benefits, choice of services, and recourse in case of dispute are available.  In most insurance programmes there are large gaps between the individual's conception of his benefits and reality. 

2. Consumer Participation and Control 
This relates to the role of patients and communities in the setting of policies and standards for health care and ascertaining that these are met.  Any proposed change must specify the manner in which such participation will occur.

Often, hospital worker/employee participation is passed for community participation. This is unacceptable as employee participation often tends toward continuing the status quo and opposing the institutional changes required to meet consumer needs. 

Another area of concern is that of the "nominated advisory board".  Such selected persons are often from the "upper class", and many are members of the interlocking directorate of the many advisory groups that governments establish to create a facade of consumer "participation".  Issues of political influence and patronage often become the major activity of these boards and they consequently fail to represent the genuine interest of the vast majority of users of the services. Consumer and neighbourhood or residents organisations must be permitted to directly nominate representatives to these boards.

Consumer participation needs to be at all levels.  At the national level, the consumer must participate in the national manpower and facilities development decisions, and in setting standards and guidelines for regional and local consumer participation.  At the state level, priorities must be set for the distribution of scarce resources, and guidelines developed for quality control of services for specific areas.  At the local level, policy decisions must be made on the style and substance for the delivery of care, the maintenance of its quality and the types of services and areas which are to receive preference.

All proposals for change must, therefore, explicitly state the exact form of consumer participation proposed

3. Eligibility
The basic principle is that the nation must assure all its citizens that their health care will at no time be compromised. This is a non-negotiable factor.  This principle, however, does not preclude the requirement that private employers contribute to any health care fund or even that individuals obtain extra-cover from private insurance arrangements.

Public facilities must continue to be made available to all persons, but especially weighted to benefit those individuals and families who cannot afford private coverage.

Age, sex, race, religion, politics or place of residence (be it state-wise or on the basis of rural and urban) should not be factors limiting access to the required level of medical care.

No pre-existing medical condition should limit a person's eligibility in any proposed plan - most commercial insurance plans in fact violate this principle.  In some countries such exclusions are a feature of public health insurance and have been used against patients with chronic illness or those in high-risk groups. 

4. Comprehensiveness and Continuity of Services
Public provision of health services should be comprehensive in the range of services provided. Included in such comprehensive coverage should be in-patient hospital care, extended care facilities and nursing homes, primary and speciality ambulatory care, dental care, mental health facilities, personal preventive medicine, rehabilitation, pharmaceuticals, prosthetic devices and other equipment including eye glasses and dentures, and adequate transportation to all health facilities.  The fundamental guiding principle should be that lack of ability to pay should be eliminated as a barrier to required/necessary health care.

Special and heavy emphasis must be placed on preventive care and on health maintenance programmes, particularly those which focus on health education and formulation of good health habits, on early reporting of remediable symptomatic diseases and screening for prompt treatment of diseases. 

5. Accessibility and Availability of Services
Eligibility and coverage are in many ways legal concepts, because a person eligible for coverage may in practice be excluded from the benefits for various reasons.  It is of no real use legislating for universal eligibility and comprehensive coverage if the requisite facilities for providing these universally are not available.  It is similarly fatuous to claim that someone in a rural area is eligible for comprehensive medical care if they are not within readily accessible distances to the required facilities.

There are a number of aspects regarding accessibility and availability of services that must be taken into account: First, there has to be an equitable geographic distribution of health care facilities. Second, there has to be an increase in the number and types of health workers in the system, and a major change in their geographic and activity distribution. Finally, there must be efforts to minimise the institutional and personnel barriers that preclude optimal utilization of facilities. Large complexes and dehumanised institutions turn patients away. Personnel barriers, which create economic, cultural or ethnic chasms between health professionals and their patients hamper effective communication.

6. Costs 
There are two different aspects in relation to cost.

First, we have to focus on such issues as prepayment or taxation costs to the consumer, with cost inflation, and, with total cost of health care to the society.  In much of Asia, the total national expenditure, both of public and private provision of health care, is below 4% of the G.N.P.  This is low. Furthermore, the experience of all countries that moved away from a system of funding health care from general government revenue to a special health care fund, however termed, has been to inflate total national health care costs. Government expenditure may decline but national expenditure invariably increases.  Hence, changes to existing systems must not be taken unless reliable estimates, and the premises, on which these estimates are based, are adequately explained and subject to rigorous scrutiny.

Second, we have to focus on the out-of-pocket expenses borne by the consumer.  The concern here is that cost must not serve as a barrier to the patient's seeking needed care whether that patient directly pays the provider, or pays a governmental agency.

The arguments frequently presented for co-payments or part payments are that they help:
(a) ration medical resources to prevent unnecessary use; and
(b) reduce the amount that must be raised by taxation or other general methods.     

However, there is a need to ensure that persons genuinely unable to pay are not denied care.  It must also be recognised that the collection of payments from the ill who are often financially handicapped by at least temporary unemployment, involves financial costs to the institution and social and emotional costs to the personnel required to administer such schemes.

7. Quality Control
Any national health programme must have built into it systems of quality control.

Large amounts of public expenditure are involved, and these must not be wasted in unnecessary or inferior services and products.  The consumer must receive the best possible care for both the preservation of his health and the treatment of his illness.

It is necessary, both for efficiency (i.e. the economy with which inputs are used to produce specified outputs) and for effectiveness (i.e. the degree to which specified goals are reached) that health services are periodically evaluated. Any national health programme must therefore specify the authority entrusted to effect quality control, and also the methods that will be employed to ensure that the said authority is effective.

Quality control must be exercised at several different levels.  At the national level standards must be set for comprehensiveness, continuity, availability, and accessibility of services and the qualification of personnel working with them.  At the local level evaluation must be made of the services provided and the institutions providing them.  In the final analysis, quality control must address the issues of outcome and effectiveness.

Outcome and effectiveness are not easily measured.  Consequently, it is common to rely on such very gross measures as infant and maternal mortality rate, life expectancy and number and type of disability days.  But such measures are not enough. Quality evaluation must also address the satisfaction of the consumer with the services obtained, the effectiveness of certain types of organization and of certain types of manpower in producing the desired results. 

Evaluation must be conducted not only by persons within the structure and institutions being evaluated, but also by those outside.  It is also necessary that the evaluation reports are made public, "sunshine is the best disinfectant."

________________________
Carmelita C.Canila, M.D

Programme Officer 
Health & Pharmaceutical

Consumers International 
Asia Pacific Office
Lot 5-1 Wisma WIM,
7 Jalan Abang Haji Openg,TTDI,
60000 Kuala Lumpur, Malaysia.
Tel: (603) 77261599
Fax: (603) 77268599
E-mail:   carmelita at ciroap.org
Websites: www.consumersinternational.org/roap , www.ciroap.org/apcl , www.ciroap.org/food

Consumers International is a federation of consumer organisations dedicated to the protection and promotion of consumers' rights worldwide through empowering national consumer groups and campaigning at the international level. It currently represents over 250 organisations in 115 countries. For more information, see: www.consumersinternational.org

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