Tuesday, June 29, 2004

Cost – Sharing in Primary Health Care

In the year 1987, the World Bank recommended that that the principle of cost recovery be incorporated into an agenda for financing publicly provided health services in developing countries. (World Bank, Findings, Africa Region)
Subject provoked many people across the globe to debate and react over it. Controversy and debate over cost-recovery system not only limited to the subject itself but also pointed so many issues relating to that. Issues like will poor able to pay? What about Government’s commitment towards peoples’ health? What about peoples’ right to equitable health? And the debate was not confined to a group, country or region; it challenged the very intension and commitment of United Nations commitment for Health for All. And now the Millennium Development Goals (MDGs).

Cost- recovery in most of the poor countries in Africa, Latin America and Asia is the bi-product of Structural Adjustment Policy or Health Sector Reform initiatives, and also a compulsion in the part of the poor National Government to adopt this because of its poor economic condition that denies free health care to its people.

What ever the reason behind the present cost-recovery system (cost sharing) there in but the ultimate truth is it does not benefit any one, neither the country nor its people. Most of the people in the third world countries are already far from the access to health service due to so many factors and the present cost-recovery system develops more gap between the people (poor) and health care. If we analyse the cost benefit or profit and loss of present cost-recovery system we will find there is little benefit or profit but more loss and burden. The poor people in the cost-recovery system are either forced to take loan from relatives or money lenders by mortgaging household assets to avail the health service or just remain in ill health and disease. Both the activities create economic burden to the family and the country. If people lost household assets or remain diseased that further breaks the chain and system of capital formation and productivity and put people vicious circle of poverty and disease. To get recover from the vicious circle of ill health and poverty both Government and People will have to spend more resources in terms of money, material, manpower and time than actually they contributed for the health services in the cost sharing.

The recent study conducted by Somali Red Crescent Society in two health centres in Somaliland where cost sharing (cost recovery) system has been initiated gives very grim picture of the initiatives.

The target set by the ministry of health for the project period that is 30 months as the community contribution in terms of user fee was 26 % of the total project cost for both of the health centres. Government contribution 5 % and rest the donor contribution. At the end of the evaluation it was estimated that local Government had contributed 2 % in one health centre and 3 % in another. Community contributed 1.5 % in one health centre and 3.5% in another centre.

The findings are revenue generated for the purpose was very small and negative impact of user fee scheme on attendance. User had resulted in reduced utilization of services and some people cannot afford the fee. Poor people are excluded from the services and many did not come for the service and some could not finish the complete treatment because they could not pay for the whole course of treatment. Study says that in Adadley health centre 1 in every 4 household had to borrow to pay the fee. Even in during drought period many patients were not exempted because health centre did not know their economic conditions.

Though the government policy says about exemption of user fee for poor, destitute, chronic patients, medical emergencies, mentally handicap without having family support, women in child bearing age, preventive services for under five children, immunization service but in reality lack of data to identify exempted persons and guidelines on user fees exclude people to get benefit of the government policy.

Here with I conclude that the paying capacity of the people, Government’s exemption or waiving policy & guideline and its enforcement, quality care and service, provision of low cost drugs, improve accessibility, etc are the key to the success of cost-sharing system.

The debate continues………………….




17 Comments:

At July 1, 2004 at 4:40 AM, Anonymous Anonymous said...

Dear Jitendra
Amazingly good job ! I always thought cost sharing in health services benefitted the people in the sense that it created a sense of responsibility and ownership and thereby sustainabilty. You have dared to venture into the less treaden areas in the debate. Provides some food for thought !

- Rekha Abraham

 
At September 4, 2004 at 1:08 PM, Anonymous Anonymous said...

Hello Panda,

Cost sharing is important but it does not work everybody, especially developing countries that are striving and meet. Nevertheless, we (developing countries) are obligated to study very closely the health systems in Cuba which not only provides free health but also educates many communities to become a health worker. In my point of view, until we understand our weaknesses and strengths in this sector the health care and thoroughly commit to level the field, we will always have this problem.

Somalia Frontiers

 
At September 4, 2004 at 1:11 PM, Anonymous Anonymous said...

Hello Panda,

Cost sharing is important but it does not work everybody, especially developing countries that are striving and meet. Nevertheless, we (developing countries) are obligated to study very closely the health systems in Cuba which not only provides free health but also educates many communities to become a health worker. In my point of view, until we understand our weaknesses and strengths in this sector the health care and thoroughly commit to level the field, we will always have this problem.

Somalia Frontiers

 
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