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<P class=MsoNormal style="MARGIN-LEFT: 0.5in"><B><FONT face=Arial color=#993300
size=2><SPAN
style="FONT-WEIGHT: bold; FONT-SIZE: 10pt; COLOR: #993300; FONT-FAMILY: Arial"></SPAN></FONT></B> </P>
<P class=MsoNormal style="MARGIN-LEFT: 0.5in"><B><FONT face=Arial color=#993300
size=2><SPAN
style="FONT-WEIGHT: bold; FONT-SIZE: 10pt; COLOR: #993300; FONT-FAMILY: Arial">Waivers
and exemptions for health services in</SPAN></FONT></B></P>
<P class=MsoNormal style="MARGIN-LEFT: 0.5in"><B><FONT face=Arial color=#993300
size=2><SPAN
style="FONT-WEIGHT: bold; FONT-SIZE: 10pt; COLOR: #993300; FONT-FAMILY: Arial">developing
countries</SPAN></FONT></B></P>
<P class=MsoNormal style="MARGIN-LEFT: 0.5in"><FONT face=Arial color=navy
size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial"></SPAN></FONT> </P>
<P class=MsoNormal style="MARGIN-LEFT: 0.5in"><FONT face=Arial color=navy
size=2><SPAN style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">Ricardo
Bitrán, Ursula Giedion<BR>October 2002<BR>Paper presented at: <B><SPAN
style="FONT-WEIGHT: bold">"Protecting the Vulnerable: The Design and
Implementation of Effective Safety Nets" - December 2-13, 2002 - World Bank
Institute - Washington, D.C.</SPAN></B></SPAN></FONT></P>
<P class=MsoNormal style="MARGIN-LEFT: 0.5in"><FONT face=Arial color=navy
size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial"></SPAN></FONT> </P>
<P class=MsoNormal style="MARGIN-LEFT: 0.5in"><FONT face=Arial color=navy
size=2><SPAN style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">Available
online as PDF file [97p.] at: <A
href="http://www.worldbank.org/wbi/socialsafetynets/courses/dc2002/readings/aldeman.pdf">http://www.worldbank.org/wbi/socialsafetynets/courses/dc2002/readings/aldeman.pdf</A>
</SPAN></FONT></P>
<P class=MsoNormal style="MARGIN-LEFT: 0.5in"><FONT face=Arial color=navy
size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial"></SPAN></FONT> </P>
<P class=MsoNormal style="MARGIN-LEFT: 0.5in"><FONT face=Arial color=navy
size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial"></SPAN></FONT> </P>
<P class=MsoNormal style="MARGIN-LEFT: 0.5in"><FONT face=Arial color=navy
size=2><SPAN style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">".......In
response to shortages in public budgets for government health services, many
developing countries around the world, have adopted formal or informal systems
of user fees for health care. In most countries user fee proceeds seldom
represent more than 15 percent of total costs in hospitals and health centers,
but they tend to account for a significant share of the resources required to
pay for non-personnel costs.</SPAN></FONT></P>
<P class=MsoNormal style="MARGIN-LEFT: 0.5in"><FONT face=Arial color=navy
size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial"></SPAN></FONT> </P>
<P class=MsoNormal style="MARGIN-LEFT: 0.5in"><FONT face=Arial color=navy
size=2><SPAN style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">The
problem with user fees is that the lack of provisions to confer partial or full
waivers to the poor often results in inequity in access to medical care. The
dilemma, then, is how to make a much needed system of user fees compatible with
the goal of preserving equitable access to services. Different countries have
tried different approaches. Those which have carefully designed and implemented
waiver systems (e.g., </SPAN></FONT><FONT face=Arial color=navy size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">Thailand</SPAN></FONT><FONT
face=Arial color=navy size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial"> and
</SPAN></FONT><FONT face=Arial color=navy size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">Indonesia</SPAN></FONT><FONT
face=Arial color=navy size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">) have had much greater
success in terms of benefits incidence than countries that have improvised such
systems (</SPAN></FONT><FONT face=Arial color=navy size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">Ghana</SPAN></FONT><FONT
face=Arial color=navy size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">, </SPAN></FONT><FONT
face=Arial color=navy size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">Kenya</SPAN></FONT><FONT
face=Arial color=navy size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">, </SPAN></FONT><FONT
face=Arial color=navy size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">Zimbabwe</SPAN></FONT><FONT
face=Arial color=navy size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">). </SPAN></FONT></P>
<P class=MsoNormal style="MARGIN-LEFT: 0.5in"><FONT face=Arial color=navy
size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial"></SPAN></FONT> </P>
<P class=MsoNormal style="MARGIN-LEFT: 0.5in"><FONT face=Arial color=navy
size=2><SPAN style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">Key to the
success of a waiver system is its financing. Systems that compensate providers
for the revenue forgone from granting exemptions (</SPAN></FONT><FONT face=Arial
color=navy size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">Thailand</SPAN></FONT><FONT
face=Arial color=navy size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">, </SPAN></FONT><FONT
face=Arial color=navy size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">Indonesia</SPAN></FONT><FONT
face=Arial color=navy size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">, and
</SPAN></FONT><FONT face=Arial color=navy size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">Cambodia</SPAN></FONT><FONT
face=Arial color=navy size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">) have been more
successful than those who expect the provider to absorb the cost of exemptions
(</SPAN></FONT><FONT face=Arial color=navy size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">Kenya</SPAN></FONT><FONT
face=Arial color=navy size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">). Where waiver systems
exist, performance will improve with the timeliness of the reimbursement. Other
success factors include the widespread dissemination of information among
potential beneficiaries about waiver availability and procedures; the awarding
of financial support to poor patients for non-fee costs of care, such as food
and transportation (as in Cambodia); and the existence of clear criteria for the
granting of waivers, thereby reducing confusion and ambiguity among those
responsible for managing the system and among potential recipients.
</SPAN></FONT></P>
<P class=MsoNormal style="MARGIN-LEFT: 0.5in"><FONT face=Arial color=navy
size=2><SPAN
style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial"></SPAN></FONT> </P>
<P class=MsoNormal style="MARGIN-LEFT: 0.5in"><FONT face=Arial color=navy
size=2><SPAN style="FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">Those
facing the task of adopting a system of waivers face multiple design options.
These include the following, among others: should exemptions be granted to whole
groups or on the basis of individual targeting (the review finds that most
systems are based on the latter)? Should waivers or exemptions be permanent or
temporary? How frequently should eligibility be reassessed? Should waiver
eligibility be determined exante, in the household, or when individuals seek
care in the facility? The review examines various approaches taken by countries,
but assessing their relative practical merits is difficult, as the evidence is
scattered and mixed......"</SPAN></FONT></P>
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