Food for a fair thought
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SOME PEARLS OF WISDOM ABOUT HEALTH CARE FINANCING
1. Equity in health means equal access for equal need.
2. Near-zero-priced public services for the poor is an essential pub-
lic policy towards equity.
3. Government intervention in the inequitable workings of the free
market is required to bring about equity in health. The problem of
resource shortages in the health sector cannot thus be seen as only a
sectoral problem.
4. Health fees are little more than an additional form of direct
taxation.
5. Changes in health care financing should be promoted because they
will improve the existing situation and not for their own (or the do-
nor's) sake.
6. Levying fees will prevent the more deprived groups from seeking
care at government facilities. It will add an additional barrier to
their use. 'Affordable' fee levels are next to impossible to set...
7. Even where efforts are made to base fees at affordable levels, the
poor will accumulate debt when faced with major illness.
8. Effectively protecting the poor from charges (fees) depends on
setting up cumbersome administrative procedures for waving fees.
9. Given that lower socio-economic groups are least likely to use
health care services, a sample survey only covering health care users
is probably biased toward higher income households.
10. The question that always needs to be kept in mind when interpret-
ing any survey results is: Does willingness to pay reflect ability to
pay?... This means that, ultimately, we need to address the ethical
issues of the impact of charges on equity.
11. From the World Bank's perspective, efficiency is the key concern
to pursue in health care financing; equity takes second place to ef-
ficiency. The Bank supports a market-based allocation of health re-
sources and envisions a limited role of government in the distribu-
tion of societal resources. But ultimately, it is the relative utili-
zation of health resources and facilities by the different socio-
economic groups which will tell us about how equitably the allocation
of these resources has been. Increasing efficiency is, therefore, not
a good enough reason to raise fees.
12. Equity considerations are of primary importance; they are of im-
portance as a policy goal. But the market-based allocation of care
discriminates against the poor --with a fee system aggravating this
situation.
13. Efficiency considerations are concerned with matters of alloca-
tion rather than distribution.
14. The basic justification for assessing equity does not change with
the level of resources available in a society: it is the same in rich
and poor countries. Moreover, limited resources do not justify
greater levels of inequity.
15. With equity in mind, the assessment of the likely impacts of pay-
ing fees on users has to be disaggregated by income distribution
quintile, and these characteristics of users (and payers) need to be
assessed before and after implementing the change.
16. The challenge definitely is finding a just balance between effi-
ciency and equity.
17. From the perspective of the poor, social and economic considera-
tions are too often forgotten in the politics of health care alloca-
tions. For instance, treatment costs per event are lower in rural ar-
eas, but transport costs for patients are significantly higher. Or,
another example to ponder: Seasons determine income and times of low
income coincide with times of potentially greatest sickness.
18. Payment exemption mechanisms and retention of revenue arrange-
ments remain grossly unaddressed in health care financing
plans....and most of the power still remains centralized.
19. Increasing access to health care is not impossible if fee reve-
nues are retained by the facilities themselves. But barriers still
exist for peripheral facilities to retain fee revenues and using them
effectively at local level with community inputs.
20. Because public expenditure is more important than taxation in the
overall distribution of income, health care expenditures should be
biased in favor of the poor. Therefore, need for health care should
be defined along the lines of the socio-economic status of house-
holds.
21. Income per capita is highly associated with demand for medical
care. Low income is a barrier to access to care.
22. Equity has to be understood as a social justice and distribu-
tional fairness issue: a more broadly-based socio-economic develop-
ment is thus a prerequisite for an improved health status that is
sustainable.
23. Worldwide, the distribution of health care is already inequitable
in socio-economic terms. It will become more inequitable increasing
the cost of care. It will reduce the demand for services by the lower
income groups and by female household members. It will also delay
presentation for care for them. Therefore, raising the cost of treat-
ment will only aggravate poverty.
24. Prices are important determinants of health care demand and that
demand is reduced more in response to price changes when income is
lower.
25. In summary, health care financing reforms alone cannot bring
about sustained better health. The promotion of wider structural
changes in society is also required. Health must thus be seen as only
a part of total care. Aiming for better universal health care forces
us to consider and tackle the unequal distribution of the circum-
stances under which preventable malnutrition, ill-health and deaths
are perpetuated.
Claudio Schuftan
Ho Chi Minh City, Vietnam
mailto:aviva@netnam.vn
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