Dina Balabanova

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.

Understanding informal payments for health care: the example of Bulgaria

INTRODUCTION Throughout the 1990s, in response to funding deficits, out-of-pocket payment has grown as a share of total expenditure in countries in transition. A clear policy response to informal payments is, however, lacking. The current study explores informal payments in Bulgaria within a conceptual framework developed by triangulating information using a variety of methodologies. OBJECTIVE To estimate the scale and determinants of informal payments in the health sector of Bulgaria and to identify who benefits, the characteristics and timing of payments, and the reasons for paying. DESIGN Data were derived from a national representative survey of 1547 individuals complemented by in-depth interviews and focus groups with over 100 respondents, conducted in Bulgaria in 1997. Informal payments are defined as a monetary or in-kind transaction between a patient and a staff member for services that are officially free of charge in the state sector. RESULTS Informal payments are relatively common in Bulgaria, especially if in the form of gifts. Informal cash payments are universal for operations and childbirth, clear-cut and life-threatening procedures, in hospitals or elite urban facilities or well-known physicians. Most gifts were given at the end of treatment and most cash payments-before or during treatment. Wealthier, better educated, younger respondents tend to pay more often, as a means of obtaining better-quality treatment in a de facto two-tier system. Since the transition, informal payments had become frequent, explicit, solicited by staff, increasingly in cash, and less affordable. Informal payments stem from the low income of staff, patients seeking better treatment; acute funding shortages; and from tradition. Attitudes to informal payments range from strongly negative (if solicited) to tolerant (if patient-initiated), depending on the circumstances. CONCLUSIONS The study provides important new insights into the incidence and nature of informal payments in the health sector in Bulgaria. Payments were less than expected, very complex, organised in a chaotic, although adaptive, system, and relatively equitable. The timing of payment and the presence of compulsion is a key factor in distinguishing between informal payments given in gratitude or as a bribe, and the latter are seen as problematic, needing to be addressed. Paying informally appeared to be a product of socio-economic reality rather than culture and tradition. The study showed that the principle of comprehensive free coverage existing in Bulgaria until 1989 has been significantly eroded. Initiating a public debate on informal payments is important in a health care reform process that purports to increase accountability.

An analysis of trends and determinants of health insurance and healthcare utilisation in the Russian population between 2000 and 2004: the 'inverse care law' in action

BackgroundThe break-up of the USSR brought considerable disruption to health services in Russia. The uptake of compulsory health insurance rose rapidly after its introduction in 1993. However, by 2000 coverage was still incomplete, especially amongst the disadvantaged. By this time, however, the state health service had become more stable, and the private sector was growing. This paper describes subsequent trends and determinants of healthcare insurance coverage in Russia, and its relationship with health service utilisation, as well as the role of the private sector.MethodsData were from the Russia Longitudinal Monitoring Survey, an annual household panel survey (2000–4) from 38 centres across the Russian Federation. Annual trends in insurance coverage were measured (2000–4). Cross-sectional multivariate analyses of the determinants of health insurance and its relationship with health care utilisation were performed in working-age people (18–59 years) using 2004 data.ResultsBetween 2000 and 2004, coverage by the compulsory insurance scheme increased from 88% to 94% of adults; however 10% of working-age men remained uninsured. Compulsory health insurance coverage was lower amongst the poor, unemployed, unhealthy and people outside the main cities. The uninsured were less likely to seek medical help for new health problems. 3% of respondents had supplementary (private) insurance, and rising utilisation of private healthcare was greatest amongst the more educated and wealthy.ConclusionDespite high population insurance coverage, a multiply disadvantaged uninsured minority remains, with low utilisation of health services. Universal insurance could therefore increase access, and potentially contribute to reducing avoidable healthcare-related mortality. Meanwhile, the socioeconomically advantaged are turning increasingly to a growing private sector.

Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening

In 1985, the Rockefeller Foundation published Good health at low cost to discuss why some countries or regions achieve better health and social outcomes than do others at a similar level of income and to show the role of political will and socially progressive policies. 25 years on, the Good Health at Low Cost project revisited these places but looked anew at Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu, which have all either achieved substantial improvements in health or access to services or implemented innovative health policies relative to their neighbours. A series of comparative case studies (2009-11) looked at how and why each region accomplished these changes. Attributes of success included good governance and political commitment, effective bureaucracies that preserve institutional memory and can learn from experience, and the ability to innovate and adapt to resource limitations. Furthermore, the capacity to respond to population needs and build resilience into health systems in the face of political unrest, economic crises, and natural disasters was important. Transport infrastructure, female empowerment, and education also played a part. Health systems are complex and no simple recipe exists for success. Yet in the countries and regions studied, progress has been assisted by institutional stability, with continuity of reforms despite political and economic turmoil, learning lessons from experience, seizing windows of opportunity, and ensuring sensitivity to context. These experiences show that improvements in health can still be achieved in countries with relatively few resources, though strategic investment is necessary to address new challenges such as complex chronic diseases and growing population expectations.

Health Care Reform in the Former Soviet Union: Beyond the Transition.

OBJECTIVE To assess accessibility and affordability of health care in eight countries of the former Soviet Union. DATA SOURCES/STUDY SETTING Primary data collection conducted in 2010 in Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Moldova, Russia, and Ukraine. STUDY DESIGN Cross-sectional household survey using multistage stratified random sampling. DATA COLLECTION/EXTRACTION METHODS Data were collected using standardized questionnaires with subjects aged 18+ on demographic, socioeconomic, and health care access characteristics. Descriptive and multivariate regression analyses were used. PRINCIPAL FINDINGS Almost half of respondents who had a health problem in the previous month which they viewed as needing care had not sought care. Respondents significantly less likely to seek care included those living in Armenia, Georgia, or Ukraine, in rural areas, aged 35-49, with a poor household economic situation, and high alcohol consumption. Cost was most often cited as the reason for not seeking health care. Most respondents who did obtain care made out-of-pocket payments, with median amounts varying from

What can global health institutions do to help strengthen health systems in low income countries

13 in Belarus to

Patterns of smoking in Bulgaria

100 in Azerbaijan. CONCLUSIONS Access to health care and within-country inequalities appear to have improved over the past decade. However, considerable problems remain, including out-of-pocket payments and unaffordability despite efforts to improve financial protection.

Implementing general practice in Russia: getting beyond the first steps

Weaknesses in health systems contribute to a failure to improve health outcomes in developing countries, despite increased official development assistance. Changes in the demands on health systems, as well as their scope to respond, mean that the situation is likely to become more problematic in the future. Diverse global initiatives seek to strengthen health systems, but progress will require better coordination between them, use of strategies based on the best available evidence obtained especially from evaluation of large scale programs, and improved global aid architecture that supports these processes. This paper sets out the case for global leadership to support health systems investments and help ensure the synergies between vertical and horizontal programs that are essential for effective functioning of health systems. At national level, it is essential to increase capacity to manage and deliver services, situate interventions firmly within national strategies, ensure effective implementation, and co-ordinate external support with local resources. Health systems performance should be monitored, with clear lines of accountability, and reforms should build on evidence of what works in what circumstances.

The persistence of irregular treatment of hypertension in the former Soviet Union

BACKGROUND Although the rate of smoking-related deaths in Bulgaria is still relatively low, in international terms, it has been rising rapidly. This is likely to become worse in the future as Bulgaria faces growing pressure from transnational tobacco companies. There is, however, little information on patterns of smoking, which is necessary for development of effective policies to tackle tobacco consumption. OBJECTIVE To describe the pattern of smoking in Bulgaria and its relationship with sociodemographic factors. DESIGN Multivariate analysis of data on patterns of tobacco consumption from a multi-stage nationwide survey of 1550 adults. SETTING Bulgaria, in 1997. MAIN OUTCOME MEASURE Prevalence of current cigarette smoking. RESULTS 38.4% of men and 16.7% of women smoke. Smoking rates are strongly associated with age, with 58% of men and 30% of women aged 30–39 smoking whereas only 5% of men aged 70 years and older and almost no women of this age smoke. Smoking is more common in cities, among those who are widowed or divorced, or who do not own their home. There is no clear association with household income or, for men, with education, although there is a suggestion that smoking may be more common among more highly educated women. CONCLUSIONS The observed pattern of smoking indicates the need for a robust policy to tackle smoking in Bulgaria, especially among the young in large cities, informed by a better understanding of why smoking rates vary among different groups.

Universal Health Coverage: A Quest for All Countries But under Threat in Some

Russia has been trying to establish a model of primary health care based on integrated general practice. Is it managing to shake off the old attitudes and infrastructures of the Soviet era?