PHA-Exchange> Removing user fees for primary care

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Removing user fees for primary care
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Dear All,

 From the latest Equinet newsletter, http://www.equinetafrica.org

REMOVING USER FEES FOR PRIMARY CARE: NECESSARY BUT NOT ENOUGH BY
ITSELF

by Lucy Gilson and Di McIntyre, EQUINET Theme Co-ordinators, Fair
Financing

User fees are once again a hot topic of policy debate. This time
the question is whether to remove primary care fees. At its con-
ference in June this year, EQUINET took a clear position on the
issue. We called for these fees to be removed. But we also
stated that this action is not a cure-all for the problems fac-
ing health systems in Africa. User fee removal must be accompa-
nied by actions that increase overall national resources for
public sector health services and that deal with international
conditions and policies that undermine this.

The two reasons why primary care fees must go are that:
* They contribute to the unaffordable cost burdens imposed on
   poor households;
* They signal to poor households that society does not care
   about them.

Fees at primary care are relatively low. Even so, there is wide-
spread evidence to show that fees encourage self-treatment (us-
ing herbs or poor quality medicine bought in unregulated market
places), deter people from taking full doses (so increasing the
chances of drug resistance), and act as a barrier to early, or
even any, use of health facilities. In these ways the small
level of fees can increase the costs poor people bear when ill.
So even though fees represent a smaller proportion of the total
costs of accessing health care than transport or lost income,
they contribute to levels of cost burden that can, in some in-
stances, impoverish poor households. At one level, impoverish-
ment results from selling key assets, cutting down on other nec-
essary expenditures, or borrowing, often at exorbitant interest
rates, to pay for health care. At another level, charging fees
adds cost to the other immense barriers of accessing care, such
as distance and abusive treatment. It signals to poor people
that they are not valued or cared for by society.

However, removing primary care fees is not enough by itself to
tackle the range of existing health care challenges in Africa.
Other actions are also required.

First, the levels of funding available for health care must be
increased. At least 15% of government budgets should be invested
in the public health sector, as committed by African governments
in Abuja. Only one country in southern Africa, Mozambique, is
currently reported to be achieving this. This will support the
sustained quality increases necessary to improve health system
performance, as well as allowing the system to respond effec-
tively to the utilization increases likely to result from fee
removal.

Linked to this African country debt should be cancelled. The
EQUINET June 2004 Conference called for international action to
remove the debt burdens imposed on African countries, and for
national action to increase the level of government funding to
health systems. These changes in financing also need to be un-
derpinned by changes in terms of trade for African countries
that result in huge resource outflows from Africa, including
market barriers in industrialized countries to trade in food
products and the poaching of health personnel.

Second, the removal of fees must be undertaken in a way that ac-
tively strengthens the health system.

In particular, the responses of health workers and managers must
be deliberately managed to avoid negative impacts on morale and
performance. As front-line providers and managers are the point
at which patients meet the health system, their morale and per-
formance has a direct influence over how patients experience
health care, and how policies are implemented. In South Africa,
while the removal of fees had a powerful positive effect on
health outcomes, health workers said they were not adequately
informed or involved, and were thus unprepared for the resulting
increases in utilization. This can lead to unnecessary tensions
at primary care level, and patients complaining that health
workers treat them badly. In countries where fees have been re-
tained, they have allowed managers and local communities some
control over the decision of how to use the revenue. In others
they have been used to fund agreed incentives for staff. These
issues need to be managed and alternative ways f!
  ound of providing for local resource control and staff incen-
tives to avoid demoralisation.

Experience from a wide range of policy actions indicates that
managing this policy change must involve:

1. Giving a specific government unit the task of implementing
fee removal in ways that strengthen the health system;
2. An effective public relations campaign to communicate the
change with the general public, and to signal that removal of
fees is about valuing patients and providers;
3. Ensuring that the policy goals are clearly explained to man-
agers and health workers to promote support for the policy at
all levels of the health system;
4. Preparatory planning to ensure adequate levels of drug and
staff availability to cope with the likelihood of initial utili-
zation increases -
and longer-term planning for how to tackle wider drug and staff-
ing, including motivation, problems;
5. Establishing new, manager-controlled funds at local level
that allow management freedom on small-scale spending decisions;
6. Clear communication with health workers and managers about
what and when actions will be taken - through meetings, supervi-
sion visits, special information letters;
7. Expect that there will be unanticipated problems with imple-
mentation, and so set up monitoring systems that provide a basis
for identifying what other actions need to be taken: monitoring
utilization trends, including the relative use of preventive
versus curative care, and giving health workers and managers op-
portunities to feed back on health facility experiences.

Tackling the human resource barriers to effective fee removal
will inevitably require the wider action that is necessary to
address the overall human resource crisis in Africa. On this is-
sue EQUINET has called for human resource policies and measures
at national, regional and international level that promote the
retention and improved working conditions of health personnel in
public sector health systems, backed by compensation for regres-
sive south-north subsidies incurred through health personnel mi-
gration. An editorial later this year will provide more detail
on this.

User fee removal clearly provides an opportunity to begin to ad-
dress the needs of poor people. However, their removal is not
enough by itself. EQUINET calls for this to be backed at na-
tional level by increased public financing for health and at in-
ternational level by a cancellation of debt. In addition, user
fee removal must be implemented in ways that strengthen the
health system. User fees were actively promoted internationally
during periods of efficiency and market led health sector re-
forms that produced a huge cost to equity in health in southern
Africa. User fee removal must be underpinned by actions at in-
ternational and national levels that provide for the resources
to achieve human rights to health and health equity goals.

* Information on EQUINET work on fair financing is available on
the EQUINET website at http://www.equinetafrica.org

EQUINET welcomes feedback to its editorials, suggestions, infor-
mation and follow up enquiries to the EQUINET secretariat at
TARSC, mailto:admin at equinetafrica.org




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