Understanding the impact of eliminating user fees: Utilization and catastrophic health expenditures in Uganda

Is the Bamako Initiative still relevant for West African health systems?

Faced with the difficulty of implementing primary health care services as proposed at Alma-Ata, UNICEF and the World Health Organization launched a new public health policy in 1987, the Bamako Initiative, to improve access to health care by revitalizing primary health care. The key principle was to decentralize retention of user fees to the local level in health centers managed by a committee of community representatives. Initially, measures were envisioned to exempt the worst-off who were unable to pay; however, these measures were never applied. Today, with most funding agencies in favor of abolishing user fees and some African countries already starting to do so, the relevance of this public policy is being reconsidered for West African countries.

Maternal and neonatal health expenditure in Mumbai slums (India): a cross sectional study

BACKGROUND

The cost of maternity care can be a barrier to access that may increase maternal and neonatal mortality risk. We analyzed spending on maternity care in urban slum communities in Mumbai to better understand the equity of spending and the impact of spending on household poverty.

METHODS

We used expenditure data for maternal and neonatal care, collected during post-partum interviews. Interviews were conducted in 2005-2006, with a sample of 1200 slum residents in Mumbai (India). We analysed expenditure by socio-economic status (SES), calculating a Kakwani Index for a range of spending categories. We also calculated catastrophic health spending both with and without adjustment for coping strategies. This identified the level of catastrophic payments incurred by a household and the prevalence of catastrophic payments in this population. The analysis also gave an understanding of the protection from medical poverty afforded by coping strategies (for example saving and borrowing).

RESULTS

A high proportion of respondents spent catastrophically on care. Lower SES was associated with a higher proportion of informal payments. Indirect health expenditure was found to be (weakly) regressive as the poorest were more likely to use wage income to meet health expenses, while the less poor were more likely to use savings. Overall, the incidence of catastrophic maternity expenditure was 41%, or 15% when controlling for coping strategies. We found no significant difference in the incidence of catastrophic spending across wealth quintiles, nor could we conclude that total expenditure is regressive.

CONCLUSIONS

High expenditure as a proportion of household resources should alert policymakers to the burden of maternal spending in this context. Differences in informal payments, significantly regressive indirect spending and the use of savings versus wages to finance spending, all highlight the heavier burden borne by the most poor. If a policy objective is to increase institutional deliveries without forcing households deeper into poverty, these inequities will need to be addressed. Reducing out-of-pocket payments and better regulating informal payments should have direct benefits for the most poor. Alternatively, targeted schemes aimed at assisting the most poor in coping with maternal spending (including indirect spending) could reduce the household impact of high costs.

Factors associated with skilled attendance at delivery in Uganda: results from a national health facility survey

Uganda has high maternal mortality ratio of 435/100,000 live births. In order to address this, Uganda has developed a strategy and has prioritized skilled attendance at delivery as a key intervention.

METHODS

A survey covering 54 districts and 553 health facilities was conducted to determine availability and access to essential maternity care and health system factors related to maternal health. The survey specifically assessed availability of emergency obstetric care (EmOC) signal functions, the state of health infrastructure and availability of basic drugs and supplies.

RESULTS

A total of 194,029 deliveries were recorded in the year preceding the survey. Majority, 117,761 (60.7%) occurred in hospitals, while 76,268 (39.3%) occurred in health centers. The following factors were associated with increased deliveries at health facilities; running water, (RR 1.5, P < .001); electricity, (RR 1.4, P < .001) and accommodation for staff, (RR 1.2, P < .002). Health units providing basic EmOC had the highest chances of attracting women to deliver there, (RR 4.0, P < .001) as well as those providing comprehensive EmOC, (RR 3.1, P < .001). Furthermore, the majority of health facilities expected to offer basic EmOC, 349 (97.2%) were not offering the service. This is the likely explanation for the high health facility-based maternal ratio of 671/100,000 live births in Uganda.

CONCLUSIONS

Improving availability and quality of care especially EmOC; and ensuring that health units have electricity, running water and accommodation for staff could increase skilled attendance at delivery and help achieve the Millennium Development Goals (MDG) target on maternal health in Uganda.

Ecological analysis of health care utilisation for China's rural population: association with a rural county's socioeconomic characteristics

Background

The problem of accessibility and affordability of health care is reported to be a major social concern in modern China. It is pronounced in rural households which represent 60% of China's population. There are a few large scale studies which have been conducted into socioeconomic inequalities in health care utilisation for rural populations. Those studies that exist are mainly bivariate analyses. The aim of this study is to examine the relationship between socioeconomic characteristics and health service utilisation among rural counties, using aggregated data from a nationally representative dataset, within a multivariate regression analysis framework.

Methods

Secondary data analysis was conducted on China's National Health Services Survey (NHSS) 2003. Aggregated data on health care utilisation, socioeconomic position, demographic characteristics and health status were used. The samples included 67 rural counties. Multivariate linear regression analyses were performed.

Results

The results of the ecological multivariate analyses showed a positive relationship between private insurance coverage and the use of outpatient care (p-value < 0.05, standardised coefficient = 0.22). Annual income was positively correlated with annual medical expenditure (p-value < 0.01, standardised coefficient = 0.56). A rural county's area socioeconomic stratum, a composite measure frequently used in bivariate studies including the NHSS analysis report, could not explain any association with the use of health care.

Conclusions

This study highlights that richer rural households with a greater ability to pay are more able to use health services in China. The findings suggest that the scope of medical insurance might be restrictive, or the protection provided might be limited, and the health care costs might still be too high. Additional efforts are required to ensure that poorer Chinese rural households are able to utilise health care according to their needs, regardless of their income levels or private insurance coverage. This would require targeted strategies to assist low income families and a broad spectrum of interventions to address the social determinants of health.

Catastrophic and impoverishing effects of health expenditure: new evidence from the Western Balkans

This paper investigates the effect of health-related expenditure on household welfare in Albania, Bosnia and Herzegovina, Montenegro, Serbia and Kosovo, all of which have undertaken major health sector reform. Two methodologies are used: (i) the incidence and intensity of 'catastrophic' health care expenditure, and (ii) the effect of out-of-pocket payments on poverty headcount and poverty gap measures. Data are drawn from the most recent Living Standards and Measurement Surveys, 2000-05. While our analyses are not without their limitations, and the lack of comparability across instruments precludes a direct comparison across countries, there is no doubt that health expenditure contributes substantially to the impoverishment of households-increasing the incidence of poverty and pushing poor households into deeper poverty-in each country. Both the catastrophic and the impoverishing effects of health expenditures are particularly severe in Albania and Kosovo. Transportation expenditure accounts for a large share of total health expenditures, especially in Albania and Serbia. Informal payments are substantial in all countries, and are particularly high in Albania. As countries in the sub-region continue the process of health system reform, an important policy question should be how to protect vulnerable groups from the catastrophic and impoverishing effects of health care expenditure.

To what extent does recurrent government health expenditure in Uganda reflect its policy priorities?

BACKGROUND

The National Health Policy 2000 - 2009 and Health sector strategic plans I & II emphasized that Primary Health Care (PHC) would be the main strategy for national development and would be operationalized through provision of the minimum health care package. Commitment was to spend an increasing proportion of the health budget for the provision of the basic minimum package of health services which was interpreted to mean increasing spending at health centre level. This analysis was undertaken to gain a better understanding of changes in the way recurrent funding is allocated in the health sector in Uganda and to what extent it has been in line with agreed policy priorities.

METHODS

Government recurrent wage and non-wage expenditures - based on annual releases by the Uganda Ministry of Finance, Planning and Economic Development were compiled for the period 1997/1998 to financial year 2007/2008. Additional data was obtained from a series of Ministry of Health annual health sector reports as well as other reports. Data was verified by key government officials in Ministry of Finance, Planning and Economic Development and Ministry of Health. Analysis of expenditures was done at sector level, by the different levels in the health care system and the different levels of care.

RESULTS

There was a pronounced increase in the amount of funds released for recurrent expenditure over the review period fueled mainly by increases in the wage component. PHC services showed the greatest increase, increasing more than 70 times in ten years. At hospital level, expenditures remained fairly constant for the last 10 years with a slight reduction in the wage component.

CONCLUSION

The policy aspiration of increasing spending on PHC was attained but key aspects that would facilitate its realization were not addressed. At any given level of funding for the health sector, there is need to work out an optimal balance in investment in the different inputs to ensure efficiency in health spending. Equally important is the balance in investment between hospitals and health centers. There is a need to look comprehensively at what it takes to provide PHC services and invest accordingly.

How to do (or not to do) ... a benefit incidence analysis

Benefit incidence analysis (BIA) considers who (in terms of socio-economic groups) receive what benefit from using health services. While traditionally BIA has focused on only publicly funded health services, to assess whether or not public subsidies are 'pro-poor', the same methodological approach can be used to assess how well the overall health system is performing in terms of the distribution of service benefits. This is becoming increasingly important in the context of the growing emphasis on promoting universal health systems. To conduct a BIA, a household survey dataset that incorporates both information on health service utilization and some measure of socio-economic status is required. The other core data requirement is unit costs of different types of health service. When utilization rates are combined with unit costs for different health services, the distribution of benefits from using services, expressed in monetary terms, can be estimated and compared with the distribution of the need for health care. This paper aims to provide an introduction to the methods used in the 'traditional' public sector BIA, and how the same methods can be applied to undertake an assessment of the whole health system. We consider what data are required, potential sources of data, deficiencies in data frequently available in low- and middle-income countries, and how these data should be analysed.

The financial burden of morbidity in HIV-infected adults on antiretroviral therapy in Côte d'Ivoire

Background

Large HIV care programs frequently subsidize antiretroviral (ARV) drugs and CD4 tests, but patients must often pay for other health-related drugs and services. We estimated the financial burden of health care for households with HIV-infected adults taking antiretroviral therapy (ART) in Côte d'Ivoire.

Methodology/Principal Findings

We conducted a cross-sectional survey. After obtaining informed consent, we interviewed HIV-infected adults taking ART who had consecutively attended one of 18 HIV care facilities in Abidjan. We collected information on socioeconomic and medical characteristics. The main economic indicators were household capacity-to-pay (overall expenses minus food expenses), and health care expenditures. The primary outcome was the percentage of households confronted with catastrophic health expenditures (health expenditures were defined as catastrophic if they were greater than or equal to 40% of the capacity-to-pay). We recruited 1,190 adults. Median CD4 count was 187/mm³, median time on ART was 14 months, and 72% of subjects were women. Mean household capacity-to-pay was $213.7/month, mean health expenditures were $24.3/month, and 12.3% of households faced catastrophic health expenditures. Of the health expenditures, 75.3% were for the study subject (ARV drugs and CD4 tests, 24.6%; morbidity events diagnosis and treatment, 50.1%; transportation to HIV care centres, 25.3%) and 24.7% were for other household members. When we stratified by most recent CD4 count, morbidity events related expenses were significantly lower when subjects had higher CD4 counts.

Conclusions/Significance

Many households in Côte d'Ivoire face catastrophic health expenditures that are not attributable to ARV drugs or routine follow-up tests. Innovative schemes should be developed to help HIV-infected patients on ART face the cost of morbidity events.

A scoping review of the literature on the abolition of user fees in health care services in Africa

In Africa, user fees constitute a financial barrier to access to health services. Increasingly, international aid agencies are supporting countries that abolish such fees. However, African decision-makers want to know if eliminating payment for services is effective and how it can be implemented. For this reason, given the increase in experiences and the repeated requests from decision-makers for current knowledge on this subject, we surveyed the literature. Using the scoping study method, 20 studies were selected and analysed. This survey shows that abolition of user fees had generally positive effects on the utilization of services, but at the same time, it highlights the importance of implementation processes and our considerable lack of knowledge on the matter at this time. We draw lessons from these experiences and suggest avenues for future research.

From targeted exemptions to user fee abolition in health care: experience from rural Zambia

Poor access to health care is one of the greatest impediments to improved health in Africa. In Zambia, user fees are considered to be partly responsible for substantial disparities in access to health care. When the Government introduced user fees in 1993, considerable concern was expressed about the adverse effects on utilisation and access. A national exemption policy was designed to protect the poorest sections of the population. However, this was largely ineffective in reaching the majority of the eligible population. On January 13th, 2006, the President of Zambia announced a policy to abolish user fees at primary health care facilities in designated rural districts. This was a major policy shift from targeted exemptions to free primary health care across the board. This study reviewed the performance of free health care in Zambia, following 15 months of implementation. Using a comprehensive national facility-based dataset, we found that utilisation increased among the rural population aged at least five years by 55%. Importantly, utilisation increases were greatest in the districts with the highest levels of poverty and material deprivation. Further, our patient exit interview survey at facilities in two rural districts reveals that although there is some evidence of a strain on drug supplies, perceptions of quality of health care remain fairly positive. This is in contrast to the experience in other countries that have removed user fees. Our findings strongly suggest that fee removal is more effective than fragmented efforts to target exemptions to certain groups in providing protection against the financial consequences of using health services.

Access to antiretroviral treatment in developing countries: Which financing strategies are possible?

BACKGROUND

In low- and middle-income countries, access to combination antiretroviral therapy for all people living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in need of treatment is a major public health challenge. The objective of this paper was to provide an overview of the different financing modalities of HIV/AIDS care at the microeconomic level and an analysis of their advantages and limitations.

METHODS

A review of the published literature using mainly the Medline and Science Direct databases for the 1990-2008 period in English and French made it possible to explore different financing strategies for the access to combination antiretroviral therapy using as case studies specific countries from different regions: Ivory Coast, Uganda, Senegal, and Rwanda for sub-Saharan Africa, Brazil and Haiti in the Latin America/Caribbean region, and Thailand for Asia.

RESULTS

In these settings, direct payment through user fees is the most frequent financing mechanism in place for HIV/AIDS care and treatment, including combination antiretroviral therapy. Nevertheless, other mechanisms are being implemented to improve access to treatment such as community-based health insurance schemes with free care for the poor and vulnerable households and public-private partnerships.

CONCLUSION

The type of financing strategy for HIV/AIDS care and treatment depends on the context. As direct payment through user fees limits access to care and does not enable program sustainability, national and donor agencies are introducing alternative strategies such as community financing systems (mutual health organizations, micro insurance, community health funds) and public-private partnerships. Finally, access to combination antiretroviral therapy has improved in resource-limited settings; however, there is a need to introduce alternative financial mechanisms to ensure long-term universal and equitable access to treatment and care, including combination antiretroviral therapy.

How access to health care relates to under-five mortality in sub-Saharan Africa: systematic review

An estimated 9.7 million children under the age of five die every year worldwide, approximately 41% of them in sub-Saharan Africa (SSA). Access to adequate health care is among the factors suggested to be associated with child mortality; improved access holds great potential for a significant reduction in under-five death in developing countries. Theory and corresponding frameworks indicate a wide range of factors affecting access to health care, such as traditionally measured variables (distance to a health provider and cost of obtaining health care) and additional variables (social support, time availability and caregiver autonomy). Few analytical studies of traditional variables have been conducted in SSA, and they have significant limitations and inconclusive results. The importance of additional factors has been suggested by qualitative and recent quantitative studies. We propose that access to health care is multidimensional; factors other than distance and cost need to be considered by those planning health care provision if child mortality rates are to be reduced through improved access. Analytical studies that comprehensively evaluate both traditional and additional variables in developing countries are required.

Changes in utilization of health services among poor and rural residents in Uganda: are reforms benefitting the poor?

BACKGROUND

Uganda implemented health sector reforms to make services more accessible to the population. An assessment of the likely impact of these reforms is important for informing policy. This paper describes the changes in utilization of health services that occurred among the poor and those in rural areas between 2002/3 and 2005/6 and associated factors.

METHODS

Secondary data analysis was done using the socio-economic component of the Uganda National Household Surveys 2002/03 and 2005/06. The poor were identified from wealth quintiles constructed using an asset based index derived from Principal Components Analysis (PCA). The probability of choice of health care provider was assessed using multinomial logistic regression and multi-level statistical models.

RESULTS

The odds of not seeking care in 2005/6 were 1.79 times higher than in 2002/3 (OR = 1.79; 95% CI 1.65 - 1.94). The rural population experienced a 43% reduction in the risk of not seeking care because of poor geographical access (OR = 0.57; 95% CI 0.48 - 0.67). The risk of not seeking care due to high costs did not change significantly. Private for profit providers (PFP) were the major providers of services in 2002/3 and 2005/6. Using PFP as base category, respondents were more likely to have used private not for profit (PNFP) in 2005/6 than in 2002/3 (OR = 2.15; 95% CI 1.58 - 2.92), and also more likely to use public facilities in 2005/6 than 2002/3 (OR = 1.31; 95% CI 1.15 - 1.48). The most poor, females, rural residents, and those from elderly headed households were more likely to use public facilities relative to PFP.

CONCLUSION

Although overall utilization of public and PNFP services by rural and poor populations had increased, PFP remained the major source of care. The odds of not seeking care due to distance decreased in rural areas but cost continued to be an important barrier to seeking health services for residents from poor, rural, and elderly headed households. Policy makers should consider targeting subsidies to the poor and rural populations. Public private partnerships should be broadened to increase access to health services among the vulnerable.

Community perceptions and factors influencing utilization of health services in Uganda

BACKGROUND

Healthcare utilization has particular relevance as a public health and development issue. Unlike material and human capital, there is little empirical evidence on the utility of social resources in overcoming barriers to healthcare utilization in a developing country context. We sought to assess the relevance of social resources in overcoming barriers to healthcare utilization.

STUDY OBJECTIVE

To explore community perceptions among three different wealth categories on factors influencing healthcare utilization in Eastern Uganda.

METHODS

We used a qualitative study design using Focus Group Discussions (FGD) to conduct the study. Community meetings were initially held to identify FGD participants in the different wealth categories, ('least poor', 'medium' and 'poorest') using poverty ranking based on ownership of assets and income sources. Nine FGDs from three homogenous wealth categories were conducted. Data from the FGDs was analyzed using content analysis revealing common barriers as well as facilitating factors for healthcare service utilization by wealth categories. The Health Access Livelihood Framework was used to examine and interpret the findings.

RESULTS

Barriers to healthcare utilization exist for all the wealth categories along three different axes including: the health seeking process; health services delivery; and the ownership of livelihood assets. Income source, transport ownership, and health literacy were reported as centrally useful in overcoming some barriers to healthcare utilization for the 'least poor' and 'poor' wealth categories. The 'poorest' wealth category was keen to utilize free public health services. Conversely, there are perceptions that public health facilities were perceived to offer low quality care with chronic gaps such as shortages of essential supplies. In addition to individual material resources and the availability of free public healthcare services, social resources are perceived as important in overcoming utilization barriers. However, there are indications that having access to social resources may compensate for the lack of material resources in relation to use of health care services mainly for the least poor wealth category.

CONCLUSION

The differential patterning of social resources may explain or contribute to the persisting inequities in health care utilization. Additional research using quantitative analytical methods is needed to test the robustness of the contribution of social resources to the utilization of and access to healthcare services.

A process evaluation of user fees abolition for pregnant women and children under five years in two districts in Niger (West Africa)

BACKGROUND

African policy-makers are increasingly considering abolishing user fees as a solution to improve access to health care systems. There is little evidence on this subject in West Africa, and particularly in countries that have organized their healthcare system on the basis of the Bamako Initiative. This article presents a process evaluation of an NGO intervention to abolish user fees in Niger for children under five years and pregnant women.

METHODS

The intervention was launched in 2006 in two health districts and 43 health centres. The intervention consisted of abolishing user fees and improving the quality of services (drugs, ambulance, etc.). We carried out a process evaluation in April 2007 using qualitative and quantitative data. Three data collection methods were used: i) individual in-depth interviews (n = 85) and focus groups (n = 8); ii) participant observation in 12 health centres; and iii) self-administered structured questionnaires (n = 51 health staff).

RESULTS

The population favoured abolition; health officials and local decision-makers were in favour, but they worried about its sustainability. Among health workers, opposition to providing free services was more widespread. The strengths of the process were: a top-down phase of information and raising community awareness; appropriate incentive measures; a good drug supply system; and the organization of a medical evacuation system. The major weaknesses of the process were: the perverse effects of incentive bonuses; the lack of community-based management committees' involvement in the management; the creation of a system running in parallel with the BI system; the lack of action to support the service offer; and the poor coordination of the availability of free services at different levels of the health pyramid. Some unintended outcomes are also documented.

CONCLUSION

The linkages between systems in which some patients pay (Bamako Initiative) and some do not should be carefully considered and organized in accordance with the local reality. For the poorest patients to really benefit, it is essential that, at the same time, the quality of services be improved and mechanisms be put in place to prevent abuses. Much remains to be done to generate knowledge on the processes for abolishing fees in West Africa.

Reducing user fees for primary health care in Kenya: Policy on paper or policy in practice?

BACKGROUND

Removing user fees in primary health care services is one of the most critical policy issues being considered in Africa. User fees were introduced in many African countries during the 1980s and their impacts are well documented. Concerns regarding the negative impacts of user fees have led to a recent shift in health financing debates in Africa. Kenya is one of the countries that have implemented a user fees reduction policy. Like in many other settings, the new policy was evaluated less that one year after implementation, the period when expected positive impacts are likely to be highest. This early evaluation showed that the policy was widely implemented, that levels of utilization increased and that it was popular among patients. Whether or not the positive impacts of user fees removal policies are sustained has hardly been explored. We conducted this study to document the extent to which primary health care facilities in Kenya continue to adhere to a 'new' charging policy 3 years after its implementation.

METHODS

Data were collected in two districts (Kwale and Makueni). Multiple methods of data collection were applied including a cross-sectional survey (n = 184 households Kwale; 141 Makueni), Focus Group Discussions (n = 12) and patient exit interviews (n = 175 Kwale; 184 Makueni).

RESULTS

Approximately one third of the survey respondents could not correctly state the recommended charges for dispensaries, while half did not know what the official charges for health centres were. Adherence to the policy was poor in both districts, but facilities in Makueni were more likely to adhere than those in Kwale. Only 4 facilities in Kwale adhered to the policy compared to 10 in Makueni. Drug shortage, declining revenue, poor policy design and implementation processes were the main reasons given for poor adherence to the policy.

CONCLUSION

We conclude that reducing user fees in primary health care in Kenya is a policy on paper that is yet to be implemented fully. We recommend that caution be taken when deciding on how to reduce or abolish user fees and that all potential consequences are carefully considered.

Beliefs about health and illness: a comparison between Ugandan men and women living with diabetes mellitus

BACKGROUND

The diabetes mellitus (DM) pandemic greatly affects developing countries. Self-care is an important part of management, guided by beliefs about health and illness. Dissimilarities in health-related behaviour in men and women have been described but not comparisons of their beliefs about health and illness.

AIM

To explore beliefs about health and illness that might affect self-care practice and healthcare-seeking behaviour in men and women with DM in Uganda.

METHODS

This was an exploratory study with a consecutive sample from an outpatient diabetes clinic at a university hospital. Semi-structured interviews were conducted with 15 women and 10 men aged 21-70 years. Data analysis was conducted by qualitative content analysis.

FINDINGS

Men's and women's beliefs about health and illness indicated limited knowledge about the body and DM. Dissimilar were men's focus on socio-economic factors, particularly affordability of drugs, sexual function and lifestyle, while women valued well-being, support in daily life and household activities and had a higher risk-awareness of DM. Irrespective of gender, limited self-care measures were used, and health professionals were consulted about health problems.

CONCLUSION

Similarities and dissimilarities were found between men and women in beliefs about health and illness that affect self-care practice and healthcare seeking. Underlying living conditions, with different gender roles, appear to determine the beliefs about health and illness, which are based on individual knowledge. Measures to increase knowledge about DM are urgently needed in Uganda. In diabetes care, it is important to search for individual beliefs and consider gender and living conditions.

Determinants of delay in care-seeking for febrile children in eastern Uganda

OBJECTIVE

To explore factors associated with delay in seeking treatment outside the home for febrile children under five.

METHODS

Using a pre-tested structured questionnaire, all 9176 children below 5 years in Iganga-Mayuge Demographic Surveillance Site were enumerated. Caretakers of children who had been ill within the previous 2 weeks were asked about presenting symptoms, type of home treatment used, timing of seeking treatment and distance to provider. Children who sought care latest after one night were compared with those who sought care later.

RESULTS

Those likely to delay came from the lowest socio-economic quintile (OR 1.45; 95% CI 1.06-1.97) or had presented with pallor (OR 1.58; 95% CI 1.10-2.25). Children less likely to delay had gone to drug shops (OR 0.70; 95% CI 0.59-0.84) or community medicine distributors (CMDs) (OR 0.33; 95% CI 0.15-0.74), had presented with fast breathing (OR 0.75; 95% CI 0.60-0.87), used tepid sponging at home (OR 0.43; 95% CI 0.27-0.68), or perceived the distance to the provider to be short (OR 0.72; 95% CI 0.60-0.87).

CONCLUSION

Even in the presence of 'free services', poverty is associated with delay to seek care. Drug shops and CMDs may complement government efforts to deliver timely treatment. Health workers need to sensitize caretakers to take children for care promptly. Methods to elucidate time in population-surveys in African settings need to be evaluated.

Paying for hospital-based care of Kala-azar in Nepal: assessing catastrophic, impoverishment and economic consequences

Households obtaining health care services in developing countries incur substantial costs, despite services generally being provided free of charge by public health institutions. This constitutes an economic burden on low-income households, and contributes to deepening their level of poverty. In addition to the economic burden of obtaining health care, the method of financing these payments has implications for the distribution of household assets. This effect on resource-poor households is amplified since they have decreased access to health insurance. Recent literature, however, ignores the importance of the method of financing health care payments. This paper looks at the case of Nepal and highlights the impact on households of paying for hospital-based care of Kala-azar (KA) by analysing the catastrophic, impoverishment and economic consequences of their coping strategies. The paper utilizes micro-data on a random selection of 50% of the KA-affected households of Siraha and Saptari districts of Nepal. The empirical results suggest that direct costs of hospital-based treatment of KA are catastrophic since they consume 17% of annual household income. This expenditure causes more than 20% of KA-affected households to fall below the poverty line, with the remaining households being pushed into the category of marginal poor; the poverty gap ratio is more than 90%. Further, KA incidence can have prolonged and severe economic consequences for the household economy due to the mechanisms of informal sector financing to which households resort. A heavy burden of loan repayments can lead households on a downward spiral that eventually becomes a poverty trap. In other words, the method of financing health care payments is an important ingredient in understanding the economic burden of disease.

Payments for health care and its effect on catastrophe and impoverishment: experience from the transition to Universal Coverage in Thailand

Equitable health financing was embodied in the reform strategies of Thailand's health care system when the country moved towards implementing the Universal Coverage (UC) policy in 2001. This study aimed to measure the pattern of household out-of-pocket payments for health care and to examine the financial catastrophe and impoverishment due to such payments during the transitional period (pre- and post-Universal Coverage policy implementation) in Thailand. This study used the nationally representative Socioeconomic Surveys in 2000 (pre-UC), 2002, and 2004 (post-UC), which contained data from 24747, 34758 and 34843 individual households, respectively. The proportion of out-of-pocket payments for health care as a share of household living standards among Thai households shows a decreasing pattern during the observed period. Moreover, the incidence and intensity of catastrophic payments for health care decline from the pre-UC to post-UC period. The distribution of incidence and the intensity of catastrophic payments for health care across quintiles also indicate that the lower quintile group (1st and 2nd quintiles) incurs lower catastrophic health care payments compared to the higher quintile group. The UC policy is also effective in preventing impoverishment due to out-of-pocket payments for health care since both the poverty headcount and poverty gap decline from the pre-UC to post-UC period. This study provides important evidence that the UC policy implementation is a valuable social protection and safety net strategy that contributes to the prevention of financial catastrophe and impoverishment due to out-of-pocket payments for health care. In conclusion, the UC policy in Thailand achieves one of the goals of improving the health system through equitable health care financing by reducing financial catastrophe and impoverishment due to out-of-pocket payments for health care.

Free care at the point of service delivery: a key component for reaching universal access to HIV/AIDS treatment in developing countries

BACKGROUND

User fees are a common feature of health system financing in low and middle-income countries. In the context of universal access to HIV/AIDS treatment and care, the advantages of user fees for funding at country and local level should be balanced with their clinical and public health impact.

METHODS

We reviewed the literature on user fees and the impact of user fees on HIV/AIDS service delivery.

RESULTS

Empirical evidence gathered since the 1980s shows that sustainability, efficiency and equity challenges faced by health systems have persisted with and have often been exacerbated by the introduction of user fees. The evidence on HIV/AIDS suggests that free care at the point of service fosters uptake and helps to extend access for the poorest users. User fees are currently the main barrier to adherence to antiretroviral therapy (ART). Their abolition is associated with better virological results and increased survival. Such abolition should be carried out in parallel with the implementation of financing mechanisms, such as prepayment and risk pooling, which are able to gather funds from the sectors of the population who are able to pay for healthcare and to promote equity towards the poorest.

CONCLUSION

WHO has included free access to HIV/AIDS treatment at the point of service delivery as a component of its public health approach for reaching universal access. Implementation of free HIV/AIDS care should, however, be linked to efforts to strengthen healthcare systems, ensure long-term sustainability of funding and monitor equity of access to care.

Protecting households from catastrophic health spending

Many countries rely heavily on patients' out-of-pocket payments to providers to finance their health care systems. This prevents some people from seeking care and results in financial catastrophe and impoverishment for others who do obtain care. Surveys in eighty-nine countries covering 89 percent of the world's population suggest that 150 million people globally suffer financial catastrophe annually because they pay for health services. Prepayment mechanisms protect people from financial catastrophe, but there is no strong evidence that social health insurance systems offer better or worse protection than tax-based systems do.

Poverty and access to health care in developing countries

People in poor countries tend to have less access to health services than those in better-off countries, and within countries, the poor have less access to health services. This article documents disparities in access to health services in low- and middle-income countries (LMICs), using a framework incorporating quality, geographic accessibility, availability, financial accessibility, and acceptability of services. Whereas the poor in LMICs are consistently at a disadvantage in each of the dimensions of access and their determinants, this need not be the case. Many different approaches are shown to improve access to the poor, using targeted or universal approaches, engaging government, nongovernmental, or commercial organizations, and pursuing a wide variety of strategies to finance and organize services. Key ingredients of success include concerted efforts to reach the poor, engaging communities and disadvantaged people, encouraging local adaptation, and careful monitoring of effects on the poor. Yet governments in LMICs rarely focus on the poor in their policies or the implementation or monitoring of health service strategies. There are also new innovations in financing, delivery, and regulation of health services that hold promise for improving access to the poor, such as the use of health equity funds, conditional cash transfers, and coproduction and regulation of health services. The challenge remains to find ways to ensure that vulnerable populations have a say in how strategies are developed, implemented, and accounted for in ways that demonstrate improvements in access by the poor.

Analysis of hospital costs as a basis for pricing services in Mali

In a move to achieve a better equity in the funding of access to health care, particularly for the poor, a better efficiency of hospital functioning and a better financial balance, the analysis of hospital costs in Mali brings several key elements to improve the pricing of medical services. The method utilized is the classical step-down process which takes into consideration the entire set of direct and indirect costs borne by the hospital. Although this approach does not allow to estimate the economic cost of consultations, it is a useful contribution to assess the financial activity of the hospital and improve its performance, financially speaking, through a more relevant user fees policy. The study shows that there are possibilities of cross-subsidies within the hospital or within services which improve the recovery of some of the current costs. It also leads to several proposals of pricing care while taking into account the constraints, the level of the hospital its specific conditions and equity.

Assessing the effect of the 2001-06 Mexican health reform: an interim report card

Since 2001, Mexico has been designing, legislating, and implementing a major health-system reform. A key component was the creation of Seguro Popular, which is intended to expand insurance coverage over 7 years to uninsured people, nearly half the total population at the start of 2001. The reform included five actions: legislation of entitlement per family affiliated which, with full implementation, will increase public spending on health by 0.8-1.0% of gross domestic product; creation of explicit benefits packages; allocation of monies to decentralised state ministries of health in proportion to number of families affiliated; division of federal resources flowing to states into separate funds for personal and non-personal health services; and creation of a fund to protect families against catastrophic health expenditures. Using the WHO health-systems framework, we used a wide range of datasets to assess the effect of this reform on different dimensions of the health system. Key findings include: affiliation is preferentially reaching the poor and the marginalised communities; federal non-social security expenditure in real per-head terms increased by 38% from 2000 to 2005; equity of public-health expenditure across states improved; Seguro Popular affiliates used more inpatient and outpatient services than uninsured people; effective coverage of 11 interventions has improved between 2000 and 2005-06; inequalities in effective coverage across states and wealth deciles has decreased over this period; catastrophic expenditures for Seguro Popular affiliates are lower than for uninsured people even though use of services has increased. We present some lessons for Mexico based on this interim evaluation and explore implications for other countries considering health reforms.

To retain or remove user fees?: reflections on the current debate in low- and middle-income countries

Many low- and middle-income countries continue to search for better ways of financing their health systems. Common to many of these systems are problems of inadequate resource mobilisation, as well as inefficient and inequitable use of existing resources. The poor and other vulnerable groups who need healthcare the most are also the most affected by these shortcomings. In particular, these groups have a high reliance on user fees and other out-of-pocket expenditures on health which are both impoverishing and provide a financial barrier to care. It is within this context, and in light of recent policy initiatives on user fee removal, that a debate on the role of user fees in health financing systems has recently returned. This paper provides some reflections on the recent user fees debate, drawing from the evidence presented and subsequent discussions at a recent UNICEF consultation on user fees in the health sector, and relates the debate to the wider issue of access to adequate healthcare. It is argued that, from the wealth of evidence on user fees and other health system reforms, a broad consensus is emerging. First, user fees are an important barrier to accessing health services, especially for poor people. They also negatively impact on adherence to long-term expensive treatments. However, this is offset to some extent by potentially positive impacts on quality. Secondly, user fees are not the only barrier that the poor face. As well as other cost barriers, a number of quality, information and cultural barriers must also be overcome before the poor can access adequate health services. Thirdly, initial evidence on fee abolition in Uganda suggests that this policy has improved access to outpatient services for the poor. For this to be sustainable and effective in reaching the poor, fee removal needs to be part of a broader package of reforms that includes increased budgets to offset lost fee revenue (as was the case in Uganda). Fourthly, implementation matters: if fees are to be abolished, this needs clear communication with a broad stakeholder buy-in, careful monitoring to ensure that official fees are not replaced by informal fees, and appropriate management of the alternative financing mechanisms that are replacing user fees. Fifthly, context is crucial. For instance, immediate fee removal in Cambodia would be inappropriate, given that fees replaced irregular and often high informal fees. In this context, equity funds and eventual expansion of health insurance are perhaps more viable policy options. Conversely, in countries where user fees have had significant adverse effects on access and generated only limited benefits, fee abolition is probably a more attractive policy option. Removing user fees has the potential to improve access to health services, especially for the poor, but it is not appropriate in all contexts. Analysis should move on from broad evaluations of user fees towards exploring how best to dismantle the multiple barriers to access in specific contexts.