Bruno Meessen

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.

Out‐of‐pocket health expenditure and debt in poor households: evidence from Cambodia

Objectives  To document how out‐of‐pocket health expenditure can lead to debt in a poor rural area in Cambodia.

Performance-based financing: just a donor fad or a catalyst towards comprehensive health-care reform?

Performance-based financing is generating a heated debate. Some suggest that it may be a donor fad with limited potential to improve service delivery. Most of its critics view it solely as a provider payment mechanism. Our experience is that performance-based financing can catalyse comprehensive reforms and help address structural problems of public health services, such as low responsiveness, inefficiency and inequity. The emergence of a performance-based financing movement in Africa suggests that it may contribute to profoundly transforming the public sectors of low-income countries.

The poorest of the poor: a poverty appraisal of households affected by visceral leishmaniasis in Bihar, India

Objective  To provide data about wealth distribution in visceral leishmanisis (VL)‐affected communities compared to that of the general population of Bihar State, India.

Output-based payment to boost staff productivity in public health centres: contracting in Kabutare district, Rwanda

OBJECTIVE In many low-income countries, public health systems do not meet the needs and demands of the population. We aimed to assess the extent to which output-based payment could boost staff productivity at health care facilities. METHODS We assessed the performance of 15 health care centres in Kabutare, Rwanda, comparing productivity in 2001, when fixed annual bonuses were paid to staff, with that in 2003, when an output-based payment incentive scheme was implemented. FINDINGS Changes to the structure of contracts were associated with improvements in health centre performance: specifically, output-based performance contracts induced sharp increases in the productivity of health staff. CONCLUSION Institutional configurations of health care organizations deserve more attention. Those currently in place in the public sector may not the most suitable to meet current challenges in health care. More experiments are needed to confirm these early results from Rwanda and elsewhere, since risks associated with output-based incentive schemes should not be ignored.

Removing user fees in the health sector: a review of policy processes in six sub-Saharan African countries

In recent years, governments of several low-income countries have taken decisive action by removing fully or partially user fees in the health sector. In this study, we review recent reforms in six sub-Saharan African countries: Burkina Faso, Burundi, Ghana, Liberia, Senegal and Uganda. The review describes the processes and strategies through which user fee removal reforms have been implemented and tries to assess them by referring to a good practice hypotheses framework. The analysis shows that African leaders are willing to take strong action to remove financial barriers met by vulnerable groups, especially pregnant women and children. However, due to a lack of consultation and the often unexpected timing of the decision taken by the political authorities, there was insufficient preparation for user fee removal in several countries. This lack of preparation resulted in poor design of the reform and weaknesses in the processes of policy formulation and implementation. Our assessment is that there is now a window of opportunity in many African countries for policy action to address barriers to accessing health care. Mobilizing sufficient financial resources and obtaining long-term commitment are obviously crucial requirements, but design details, the formulation process and implementation plan also need careful thought. We contend that national policy-makers and international agencies could better collaborate in this respect.

Performance-based financing toolkit

Performance-based financing (PBF) approaches have expanded rapidly in lower-and middle income countries, and especially in Africa. The number of countries has grown from three in 2006 to 32 in 2013. PBF schemes are flourishing and cause considerable demand for technical assistance in executing these health reforms in a rational and accountable manner. Currently there is a lack of knowledge among many health reformers of how to implement performance-based financing pilot projects, and scale them up intelligently. In a context of tremendous demand for solid design and implementation experience and given the rapid expansion of results-based financing (RBF) programs, there is an urgent need to build capacity in designing and implementing PBF programs. As yet there has been little attempt to gather the learning from these experiences together in one volume and, moreover, in a form that serves as a guide to implementers. This toolkit answers the most pressing issues related to the supply-side RBF programs of which PBF forms part.

Editorial: Iatrogenic poverty

keywords poverty, iatrogenesis, catastrophic health care expenditure, health insurance, socialassistance, Asia, transitionPoverty and illness are intertwined. It is a well-documentedfact that poverty leads to ill-health. In every society,morbidity and mortality are higher among the poor(Wagstaff 2002). Determinants of lower health statusinclude nutrition, environment, education, lifestyle andaccess to health care. Less is known about how illness itselfcan lead to poverty in developing countries. There are twomajor pathways. The first is through the death or disabilityof a household income earner. This reduces future incomegeneration and may jeopardize household consumption.After a household has depleted its wealth it may have lesscapacity to invest in the education of their children. Thistransmits poverty to the next generation.The second is through the treatment itself, or moreexactly its cost. The chain of events is as follows: whensomeone falls ill, the household faces several different costs(opportunity cost of care giving, transportation, treat-ment), and to cope with them, it follows diverse strategies.Sometimes the costs are limited, and the household is ableto buffer them by making a short-term adjustment (such asconsuming precautionary saving, calling on assistance frominformal support networks, temporarily reducing its con-sumption of other goods). Yet, sometimes, the costs are at,or increase to, a level where these coping mechanisms arenot sufficient anymore. The household then adopts theriskier strategies of selling or mortgaging its productiveassets (Ensor & Bich San 1996; Bloom & Lucas 2000;Meessen & Criel 2003). Some households recover from thefinancial shock, but others do not (Wilkes et al. 1997). Thenext time when they have to deal with an illness, a cropfailure or another problem, they may be tipped intopoverty. Chambers (1983) has called this process a povertyratchet.Iatrogenic povertyPoor people are well aware of that cycle. Surveys havefound that they identify sickness as one of their greatestworries (Milimo et al. 2002). Economists and experts inpoverty analysis have raised the issue. The WHO, theWorld Bank and the ILO are trying to put it higher on theagenda by referring to it as catastrophic health careexpenditure. But the issue is still little recognized by thepolitical, scientific and, most of all, the medical commu-nities. Doctors are trained to assess the outcome of theirinterventions in terms of health status, it is high time toconsider them in terms of welfare.Let us have a look at the world outside the health sector.What has been the major change for humanity these lasttwo decades? The average reader of this journal mightidentify globalization. But for 1.7 billion people, the majorchange has another name: transition. The transition from aplanned economy to a market economy has concernedChina, most of South East Asia, Eastern Europe and theRepublics of the former Soviet Union. What has thistransition meant for the citizens of these countries?Economic growth in some countries, but also a reshapingof the pattern of entitlements (Sen 1981). While education,jobs, income and welfare services used to be taken forgranted, today they are determined by a combination ofmarket forces and political commitment to provide bene-fits. One can find a job and earn an income according toone’s skills and the demand in the labour market. Access toeducation and health care are no longer universal, but areinfluenced by the ability to pay.Most governments fail to fund their health sectoradequately because of limited budgets, excessive faith inmarket forces or other priorities. Consequently, manypublic health care facilities are run down or they generaterevenue by charging patients. At the same time, ruralhouseholds in many countries have a new opportunity tomortgage or sell their land and other productive assets.Marketization is indeed ubiquitous. Today, more thanever, the Cambodian or Chinese farmer is able tomatch his ability to pay for health care with his willing-ness to pay. Credit and land markets, i.e. usurious

Performance-based financing as a health system reform: mapping the key dimensions for monitoring and evaluation

BackgroundPerformance-based financing is increasingly being applied in a variety of contexts, with the expectation that it can improve the performance of health systems. However, while there is a growing literature on implementation issues and effects on outputs, there has been relatively little focus on interactions between PBF and health systems and how these should be studied. This paper aims to contribute to filling that gap by developing a framework for assessing the interactions between PBF and health systems, focusing on low and middle income countries. In doing so, it elaborates a general framework for monitoring and evaluating health system reforms in general.MethodsThis paper is based on an exploratory literature review and on the work of a group of academics and PBF practitioners. The group developed ideas for the monitoring and evaluation framework through exchange of emails and working documents. Ideas were further refined through discussion at the Health Systems Research symposium in Beijing in October 2012, through comments from members of the online PBF Community of Practice and Beijing participants, and through discussion with PBF experts in Bergen in June 2013.ResultsThe paper starts with a discussion of definitions, to clarify the core concept of PBF and how the different terms are used. It then develops a framework for monitoring its interactions with the health system, structured around five domains of context, the development process, design, implementation and effects. Some of the key questions for monitoring and evaluation are highlighted, and a systematic approach to monitoring effects proposed, structured according to the health system pillars, but also according to inputs, processes and outputs.ConclusionsThe paper lays out a broad framework within which indicators can be prioritised for monitoring and evaluation of PBF or other health system reforms. It highlights the dynamic linkages between the domains and the different pillars. All of these are also framed within inter-sectoral and wider societal contexts. It highlights the importance of differentiating short term and long term effects, and also effects (intended and unintended) at different levels of the health system, and for different sectors and areas of the country. Outstanding work will include using and refining the framework and agreeing on the most important hypotheses to test using it, in relation to PBF but also other purchasing and provider payment reforms, as well as appropriate research methods to use for this task.

Studying the link between institutions and health system performance: a framework and an illustration with the analysis of two performance-based financing schemes in Burundi

Institutional arrangements of health systems and the incentives they set are increasingly recognized as critical to promote or hinder performance in the health sector. Looking at complex health system interventions from an institutional perspective may contribute to better understanding what are the paths and processes that lead to the results of such interventions. In this article, we propose an analytical framework drawing from new institutional economics. This framework suggests seven dimensions to look at: institutions, enforcement mechanisms, property rights, incentives, interactions between extrinsic and intrinsic sources of motivation, behavioural changes and organizational performance. For illustrative purposes, we then apply the framework to the analysis of the institutional (re)arrangements of two performance-based financing (PBF) schemes in Burundi by carrying out an empirical comparison of case studies. We use mainly qualitative data from primary and secondary sources and analyse them with focus on the seven dimensions of the framework. The analysis of the case studies provides a comparative narrative of the two PBF schemes and highlights the differences in their operational design, the challenges faced during implementation and the adaptations made. From a methodological perspective, this article proposes a tool to analyse complex health system interventions, looking beyond the evaluation of the final effects to focus on the processes through which institutional (re)arrangements affected those results. Its application indicates, at an empirical level, that such analysis could help identify lessons regarding the design of health systems interventions, such as PBF schemes, and the process of reforming institutional arrangements.