E-DRUG: Sach's unfahionable Rx for third world aid (2)
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Greetings,
I am wondering if there is more information and evidence available about the statement Sachs' made on user fees. Mercy Ships offer free medical care with no attached charges at all, but we often hear similar remarks (pointedly not from the patients themselves but more usually from
spectators), about how a minimal charge somehow adds value to the remedies
or drugs in the eyes of the receiver. It is not our experience but I would
be interested if there is some kind of concrete information or evidence or
even experiences from others that we can refer to. In the nations we serve
(often amongst the last 20 of the UN Human Development Index category like
Liberia and Sierra Leone), most of our patients would not even be able to
afford the 1 dollar or 50 cents as their income is already just 1 USD a day
or less. As this is not a normal E-Drug topic I leave it in the hands of the moderator whether to include this.
[There are numeorus publications on user fees, also in the e-drug archives. User fees are used in drug revolving funds (DRF), Bamako Initiative projects etc. Moderator]
Kae
Kae Ting TROUILLOUD
Pharmacy Manager/Editor of the Mercy Ships Formulary
Mercy Ships International
with M/V Anastasis, currently docked in Tema, Ghana
E-DRUG: Sach's unfashionable Rx for third world aid (3)
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Hi E-druggers
Perhaps the value in user fees is not in making the patient value the
treatment but in signalling to the caregivers involved that treatment
actually costs something. A common attitude is that as medicines etc
are "public" property or are "donations" and thus a little leakage or
waste is not hurting anybody. In a similar way at times prescribers
may over prescribe to cover all eventualities because the drugs are
free anyway.
Introduction of a user fee after treatment has been free for a long
period of time is unlikely to be successful initially as it takes time
for attitudes to change. Thus it is very hard to transform an
essentially free service into a revolving fund. In the end I suppose
that it all comes down to long term funding and how committed the
community and the donors are to setting up a sustainable long term
treatment program.
These is just my impression of the way that the world works.
Paul
--
Paul Lobb
email paul.lobb@gmail.com
unaffiliated pharmacist
E-DRUG: Sachs' unfashionable Rx for third world aid (4)
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As Sierra Leone, my home country, has been correctly referred to as one of
those "amongst the last 20 of the UN Human Development Index category.."
and as I was directly involved as Health Project Officer with
implementation of the "Bamako Initiative" for many years, before the civil
war hustled everybody away, I can say the following:
Although admittedly with no hard evidence, it was often claimed in
statements by community leaders at programme launching ceremonies that
communities generally believed that "free" can never be "best".
User fee or no user fee, was often not the issue, but whether supplies
will be available when required. Unfortunately, in communities where
government capacity could not be relied on, it is true that collection
and good management of user fees did, at least in the Sierra Leone case,
result in better assurance of supplies. Briefly, UNICEF Sierra Leone
had, in view of foreign exchange difficulties the country faced, a
special concession with government whereby collected local currency from
districts, through user fees, were used in their in-country programme
implementation, and the equivalent foreign currency provided to finance
import of essential medicines for districts who paid. It was as
hard-nosed as "no money, no medicine" in this programme. There was at
least qualitative evidence that health facilities in districts where the
Bamako Initiative was not yet launched were worse off in a number of
indicators. This hopefully may have translated into better health
indicators. However, it must also be said that the government did not
renege on its commitment to provide free medicines to all its peoples.
Translating commitment to reality boiled down to resource availability
and good governance.
Even where user fees are felt to be helpful, it should never be
overlooked that there has to be safety nets on which some/many members
of the community can fall. The problem would be how to identify and
provide safety to those vulnerable.
It is important to emphasise that it is not entirely what and how much
resources are available, through user fees or otherwise, but how well
they are managed.
Murtada M. Sesay
Technical Officer (Pharmaceuticals)
UNICEF Supply Division
E-DRUG: Sachs' unfashionable Rx for third world aid (5)
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Dear all,
I would concur with Paul Lobb's comments on user fees. From my own
experience of working on a revolving dug fund, these
programmes require long- term commitment from all stakeholders (seed
funding, project institution, the community). They also
require narrowing focus, by only charging for one area, such as the
prescription. I was fortunate enough to have worked on such a
programme that had received over 15 years of support from a donor,
providing technical and administrative support, then transferring
funding support from top- up of funds to facilitating a
a currency swap mechanism. Even after hand-over, the donor was still
providing occassional support through its country office. At the time
I worked on the programme, there was visible political commitment
(going as far as Parliament), and strong support from the communities
and the public health services.
That sort of commitment from donors is certainly costly (in more ways
than one!) to the donor, but clearly necessary if success is to be
achieved.
However, such programme need to ensure that full services remain
available to the poor and those that are unable to pay, and to that
end, various approaches have been tried on many programmes that are
published.