Whether Governments should charge patients fees to use public health services has become one of the most contentious social policy issues worldwide. Sadly for policy makers, in recent years, the quality of debate in this area has often been poor, with opposing camps usually resorting to unproven theory and emotive rhetoric. Perhaps a new perspective should be brought to this debate. How would the world of business deal with this problem; which in effect, is an issue of what (if any) price one should charge for health services?
Resource allocation and health financing
International experiences in removing user fees for health services; Implications for Mozambique
Yates R: DFID Health Resource Centre, 2006
International health financing and the response to AIDS
Lieberman S, Gottret P, Yeh E, de Beyer J, Oelrichs R and Zewdie D: Journal of Acquired Immune Deficiency Syndromes 52: S38–S44, November 2009
Efforts to finance HIV responses have generated large increases in funding, catalysed activism and institutional innovation, and brought renewed attention to health issues and systems. The benefits go well beyond HIV programmes. The substantial increases in HIV funding are a tiny percentage of overall increases in health financing, with other areas also seeing large absolute increases. Data on health funding suggest an improved pro-poor distribution, with Africa benefiting relatively more from increased external flows. A literature review found few evidence-based analyses of the impact of AIDS programmes and funding on broader health financing. Conceptual frameworks that would facilitate such analysis are summarised.
Interview with Global Fund director Michel Kazatchkine
Plus News: 12 March 2010
In this interview, the executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, Michel Kazatchkine answers some questions about HIV and AIDS funding at the launch of the organisation's 2010 report. He said that he considered AIDS an exceptional threat, quoting the large numbers affected by the epidemic. He did not think that too much has been invested in HIV and AIDS to the detriment of other illnesses, pointing out that over a third of the overall funding of the Global Fund goes to strengthening health systems. The interview reports on the limited impact of the financial crisis on the Global Fund, the significant contribution of the Fund to anti-retroviral treatment in low-income countries and observations on the channels for the funds of the organisation.
Interview: How do you quantify malaria’s economic damage?
China Global Television Network (CGTN) Africa, April 2017
Despite decades of interventions, malaria is still one of the biggest killer diseases in Africa continent. In 2015 alone, an estimated 429 000 people died of malaria according to the World Health Organisation, 90% of them in Africa. Beyond the lives lost, how much economic damage does malaria really do to sub-Saharan economies? That’s a question CGTN's Ramah Nyang explored in conversation with the CEO of the African Medical & Research Foundation.The drug RTSS prevents more than forty strains of malaria in toddlers. It is being rolled out to more than 300 000 children in Kenya, Ghana and Malawi in trials and more vaccines are being tested. It is unlikely that one vaccines will eradicate all malaria, but testing vaccines can significantly reduce the impact of malaria. Malaria was eradicated in Europe and America in the 1930s and many are asking why this cannot be done again in Africa.
Investing in health
Yates R, Dhillon R: The Lancet, Volume 383, Issue 9921, 949 - 950, 15 March 2014
Public financing is the path to universal health coverage (UHC). UHC is rapidly becoming the overarching goal for national health systems and two recent events mark a new consensus that public financing is the way to get there. The Lancet Commission on Investing in Health2 focused on public financing mechanisms (including aid) in reaching UHC and explicitly rejected the 1993 World Development Report's emphasis on private health financing, including user fees. Similarly all 11 countries that presented at the Global Conference on UHC (Dec 6, 2013, Tokyo, Japan) hosted by the World Bank and Government of Japan, highlighted their use of public financing to increase service coverage and improve financial protection. None had used private voluntary financing to any significant extent. What is the basis for this consensus? UHC is fundamentally about rights and equity. It requires that the healthy and wealthy subsidise health services for the sick and poor. This cannot happen through private market-based systems of user fees and private insurance, including voluntary community-based schemes.Across the world, countries are instead realising that the only way to secure the cross-subsidies needed for UHC is through compulsory contributions into redistributive risk pools. In particular, tax financing is proving essential to close coverage gaps for households in the informal sector. Since only the state can mandate progressive payments and ensure that benefits are allocated according to need, only public financing systems can achieve the combination of universality, equity, and financial protection needed for UHC. Many of the governments that have learnt these lessons are now the ones leading the charge for UHC to be included in the post-2015 agenda. As noted by the World Bank President, one of these countries, Thailand, achieved UHC by rejecting the advice of the World Bank in the 1993 World Development Report to not rely on public financing. These countries represent the new consensus on health financing: universal coverage can only be accomplished through public financing systems in which the state plays a leading part in raising revenues, pooling funds, and purchasing services.
Investing in health for development: Experiences from national follow-up to the Commission on Macroeconomics and Health
Spinaci S, Currat L, Shetty P, Crowell V, Kehler J
This report presents country experiences in developing and shaping work to address long-term planning for the health sector. It identifies areas of action to which the national commissions have contributed, from mobilising political will and building much-needed evidence, to strengthening national planning processes. These lay the groundwork for sustainable improvements in health for the world’s poor people. The report clarifies the most intractable challenges that have impeded faster health progress, and gives concrete examples of how countries have started to address them through an integrated approach to health sector development and financing.
Investment in child health 'inadequate'
This commentary from the Lancet argues that investment in maternal, newborn and child health remains seriously inadequate, despite its crucial importance not only for saving lives but also for achieving poverty reduction, equity and other human development goals. The authors point out that the most effective package of interventions for reducing mortality in both women and newborns – female education, family planning, community-based maternity care, and referral services for women with obstetric complications – has received little attention from policymakers.
Is global interest in the Tobin tax genuine?
Guise A: EG4Health, 4 December 2009
The idea of a Tobin tax is suddenly popular amongst many who have long opposed it. The United Kingdom’s Prime Minister, Gordon Brown, has even come out in favour of the tax and the G20 have asked for further research to be done in this area. But this interest from the dominant institutions and governments running the global economy could act to prevent discussion on other much-needed reform. So what lies behind the interest in a Tobin tax? One response is that it is quite simply a good idea. It has the potential to raise billions of dollars and would help control a finance industry that has floated free of ideas of needing to benefit wider society. A second response then to what lies behind the talk of a Tobin tax is that while it would be a radical reform, it may be a politically handy ‘trick’ to cover the lack of even more radical reform. Institutions like the International Monetary Fund (IMF) and Gordon Brown could see implementing the Tobin tax as a useful way of escaping a deeper scrutiny of the flaws in the global economy and how it is run. Meanwhile, the unequal system that perpetuates ill-health and poverty continues.
Is it all about the money? A qualitative exploration of the effects of performance-based financial incentives on Zimbabwe's voluntary male medical circumcision program
Feldacker C; Bochner A; Herman-Roloff A et al.: PLoS ONE 12(3), 2017, doi:10.1371/journal.pone.0174047
In 2013, Zimbabwe’s voluntary medical male circumcision (VMMC) program adopted performance-based financing (PBF) to speed progress towards ambitious VMMC targets. The PBF intended to encourage low-paid healthcare workers to remain in the public sector and to strengthen the public healthcare system. The majority of the incentive supports healthcare workers who perform VMMC alongside other routine services; a small portion supports province, district, and facility levels. This qualitative study assessed the effect of the PBF on healthcare worker motivation, satisfaction, and professional relationships. The study objectives were to: 1) Gain understanding of the advantages and disadvantages of PBF at the healthcare worker level; 2) Gain understanding of the advantages and disadvantages of PBF at the site level; and 3) Inform scale up, modification, or discontinuation of PBF for the national VMMC program. Sixteen focus groups were conducted: eight with healthcare workers who received PBF for VMMC and eight with healthcare workers in the same clinics who did not work in VMMC and, therefore, did not receive PBF. Fourteen key informant interviews ascertained administrator opinion. Findings suggest that PBF appreciably increased motivation among VMMC teams and helped improve facilities where VMMC services are provided. However, PBF appears to contribute to antagonism at the workplace, creating divisiveness that may reach beyond VMMC. PBF may also cause distortion in the healthcare system: Healthcare workers prioritised incentivised VMMC services over other routine duties. To reduce workplace tension and improve the VMMC program, participants suggested increasing healthcare worker training in VMMC to expand PBF beneficiaries and strengthening integration of VMMC services into routine care. In the low-resource, short-staffed context of Zimbabwe, PBF enabled rapid VMMC scale up and achievement of ambitious targets; however, side effects make PBF less advantageous and sustainable than envisioned. Careful consideration is warranted in choosing whether, and how, to implement PBF to prioritise a public health program.
Is More Information Better? The Effects of 'Report Cards' on Health Care Providers
Health care report cards - public disclosure of patient health outcomes at the level of the individual physician and/or hospital - may address important informational asymmetries in markets for health care, but they may also give doctors and hospitals incentives to decline to treat more difficult, severely ill patients. Whether report cards are good for patients and for society depends on whether their financial and health benefits outweigh their costs in terms of the quantity, quality, and appropriateness of medical treatment that they induce. Using national data on Medicare patients at risk for cardiac surgery, we find that cardiac surgery report cards in New York and Pennsylvania led both to selection behavior by providers and to improved matching of patients with hospitals. On net, this led to higher levels of resource use and to worse health outcomes, particularly for sicker patients. We conclude that, at least in the short run, these report cards decreased patient and social welfare.