In the current environment of shrinking global and domestic resources for health care, there is an overwhelming pressure to achieve financial sustainability in the health sectors of developing countries. Within this context, there seems to be increasing acceptance of the view that individuals need to contribute to some of the costs of public health care through charges such as user fees and other cost-recovery mechanisms. This paper looks at the implications of user fees for women's utilization of health care services, based on selected studies in Africa. Lack of access to resources and inequitable decision-making power mean that when poor women face out-of-pocket costs such as user fees when seeking health care, the cost of care may become out of reach. Even though many poor women may be exempt from fees, there is little incentive for providers to apply exemptions, as they too are constrained by restrictive economic and health service conditions. If user fees and other out-of-pocket costs are to be retained in resource-poor settings, there is a need to demonstrate how they can be successfully and equitably implemented. The lack of hard evidence on the impact of user fees on women's health outcomes and reproductive health service utilization reminds us of the urgent need to examine how women cope with health care costs and what trade-offs they make in order to pay for health care.
Public-Private Mix
The World Bank and International Monetary Fund favour healthcare user fees. User fees offer revenue and may decrease inappropriate care. However, user fees may deter needed care, especially in vulnerable populations. A cross-sectional analysis of healthcare utilization in a large Zambian hospital was conducted for children 3-6 years of age during a one-month observation period. Trends suggest female children may be less likely to present for care when user fees are imposed. This paper concludes that user fees appear to decrease differentially utilization of inpatient care for female children in rural Zambia.
Improving the quality of private health care provision in developing countries is of major importance to the livelihoods of poor people. This article was published in the ‘Bulletin of the World Health Organisation’ and summarises how the activities of the private health sector in low-income countries can be influenced so that national health objectives are met. The article begins with an overview of the characteristics of the private health sector in developing countries. It continues with a summary of how to improve both the supply and the demand for private health care. To close, the authors list the possibilities available to governments for improved stewardship of the private sector.
Public-private partnerships are increasingly popular initiatives in international health. The Global Alliance for Vaccines and Immunisation (GAVI) was launched in January 2000 with a donation of US$ 750 million from the Bill and Melinda Gates Foundation. An assessment of its work by researchers at the London School of Hygiene and Tropical Medicine reveals important lessons for similar initiatives, including the new Global Fund to Fight AIDS, Tuberculosis and Malaria.
Often some government and donor officials have denied that Malawi will privatise nearly every lifeline. But progress indicates that the government intends to privatise institutions providing food security in Malawi, water, electricity and more. This will translate into the livelihood of the people being at the mercy of 'forces of the market'. This privatisation behaviour has been opposed by civil society, says this briefing from the Malawi Economic Justice Network.
This report, produced by Population Action International, argues that condom promotion and provision is one of the most effective methods for preventing HIV/AIDS. They state that 8 billion would have been the minimum number of condoms to have made a difference to the spread of HIV in 2000, and that the 950 million provided by donors were therefore hugely inadequate. The report says that a number of different interventions are necessary for effective prevention programmes: the authors highlight the need for addressing poverty, gender inequity and promoting the 'ABCs' of abstinence, fidelity and condom use. However, they state that the mix of interventions must always include condoms. In calling for universal access to condoms, the report states that public/private partnerships will be necessary and that market segmentation, whereby those who can afford to pay more than the poorest, should be encouraged.
Edited by Alexander S. Preker , David M. Dror, World Bank
Traditional sources of health care financing are often inadequate leaving many of the 1.3 billion poor people in low- and middle-income countries without access to the most basic health services. Governments in these countries have tried to reach these excluded populations through public clinics and hospitals. To help pay for these services, governments often use a combination of broad-based general revenues, contributions from the formal labor force, and user fees, similar to the financing mechanisms used by Western industrial countries. However, these mechanisms are not always effective in many developing countries, leaving many of the poor without essential health care or financial protection against the cost of illness. Social Reinsurance details community-based approaches to insuring people against medical risk not based on individual risk rating as in private insurance, but rather using decentralized social insurance based on the average risk.
Effective treatment of curable sexually transmitted infections (STIs) is one of the few strategies available to reduce the spread of HIV in sub-Saharan Africa. Many people with STIs seek treatment from private practitioners. Why are patients turning to the private sector for help? Do they receive adequate care?
The Civil society health caucus at the WSSD Global Forum hosted a Commission to discuss the Role of the of the state and water, sanitation and primary health care in the context of globalisation. The discussion included analysis of the situation which raised the following points.
• Debt and globalisation impact negatively on the distribution of all resources, including environment and health through their destruction and privatization.
• Environmental degradation increases the burden of ill health
• Lack of knowledge about environment and health and hygiene are sorely lacking amongst many citizens, especially children.
• Environmental services are a basic right which every citizen should enjoy
• Privatisation of services, including through public private partnerships, has been a very negative experience for many poor people, especially women and children, in countries as diverse as the UK and Argentina
• War and military occupation both severely restrict access to health and basic services, and conflict and psychological stress are also increasingly a result of struggles for access to these services.
The concept of 'managed competition' to improve efficiency has been common in health sector reform in wealthy countries. It has also been exported to health systems in the South, involving privatisation and marketisation. Research from the UK Institute of Development Studies questions whether this competitive approach is appropriate in a sector where ethical behaviour, altruism and co-operation are essential for good quality services.