Contact n°146 December 1995 - January 1996 : Health financing crisis: Can communities afford to pay?

20 Pages·1995·6.6 MB·English

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A publication of the CMC-Churches’ Action for Health, World Council of Churches
HEALTH FINANCING CRISIS ©
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HEALTH FINANCING Crisis Pharmaceutical adviser
no 146 2 Editorial Can Bamako help solve the
crisis?
December 1995 - 3 Health workers
January 1996 ; Speaking up for the poor in Chile Resource materials
6 PHC administrator
UPDATE
Cost recovery can work!
16 Nuclear testing in the Pacific,
9 Programme manager Women and HIV: Beijing and India
Questioning the “Robin Hood”
approach NETWORKING
12 Programme director 19 Letters, Useful publications and
When ducks pay the health bills Announcements
EDITORIAL
Earlier this year, Contact 141 Financing munity aspires. Nevertheless, he still
Health Care described the changing maintains that in a caring society, the
policy and thinking in health financing. state should be responsible for the main-
We asked you to respond to the debate tenance of health as a right for all.
about these changes from your local
In contrast to the success in Cameroon,
experiences. We were not disappointed.
the experience in India (page 9) was
In this issue of Contact, we provide
different. Daleep Mukarji found that com-
some of the many responses received
munity cost-recovery schemes benefited
from readers. |
the rich to a greater extent than the
The first article is an interview by Contact poor. Like David Werner, he cameto the
reader Karen Anderson who works with conclusion thatit was vital to ensure that
EPES in Chile. She and a colleague the service or project was the aspiration
spoke to two health workers from the of a fully-participating community.
urban squatter communities of Santiago
Inthe Philippines, Carl Salem, who says
about the effects of structural adjust-
In India, community he has been reading Contact for many
ment programmes (SAPs) and privati-
years, felt that the only way to ensure
cost-recovery zation policies on health care. World
that the poor had the funds they needed
schemes benefited Bank adherents claim that these policies
to pay for health care was to create
have been a great success in Chile.
the rich to a greater source of reliable income. Now, all healt
. These health workers think differently.
bills are paid in kind — in ducks’ eggs.
extent than the
In particular, they say that poor com-
poor. munities like theirs face declining public Finally, we provide an update on the -
services as more and more privatization Bamako Initiative which aims to bring
takes place. They cannot afford to pay - more money into local health services.
for private health services as they are Although spreading worldwide, there
expected to do, but they are not poor remain problems. High-risk groups are
enough to be defined as “indigent” and excluded from services, there are risks
therefore entitled to help. The reaction of over-prescribing, and in some cases,
of these community health workers to community involvement is threatened
their appalling situation is simply to by administrative burdens.
strengthen their efforts to organize and
We hope that these articles will prove to
fight with the poor. be an inspiration to you. Do write and let
The second article comes from a rural us know. We welcome your letters.
setting in Cameroon. A primary health
care (PHC) programme administrator
says she disagrees with David Werner’s
opposition to cost recovery (Contact
141, page 1-4). She says that her pro-
gramme is able to recover costs in an pzt eh
equitable way. In answer to her letter,
m7 Z 5
David Werner says that cost recovery
canbe benevolentif the service is some-
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2
contact n°146 - December 1995-January 1996 .
HEALTH WORKERS
SPEAKING UP FOR THE POOR IN CHILE
In this interview, two health
: promoters trained by EPES
(Educacion Popular en Salud) in
Chile describe the effects of health
reform in their communities. They
say that the poorest communities
find themselves paying more for
fewer, poorer quality services. The
asics eosin etinennean ane OLMEDLEOR E.DEL AEDS
be women believe that the only way
ahead is to continue to organize
within their communities, and to
speak up as often as they can on
behalf of the poor.
Introduction |
The World Bank and other international
financial institutions have presented
Chile as amodel of economic and social
reforms. The results of privatization,
liberalisation and deregulation have
received lavish praise in international
circles. But from the perspective of the
oor, it is crystal clear that access and
ality of health services have seriously
deteriorated.
The first major decline in the quality of
services began in 1973 when the mili-
tary dictatorship of Pinochet came to
power. After the coup, the military fired
thousands of health professionals and
health workers, and banned and perse- SaJArli/dgC ahdrois tian
cuted members of the National Health
Patchwork workshop in
Workers Federation (FENATS). The
Santiago, Chile
reform process led to a cut in the health services for lower income workers on
budget for the first time in decades. public funds. During the 1980s, primary
health services began to be transferred
In 1980, also on the recommendations
to the municipalities, and in 1986, cost
of the World Bank and IMF, the National
recovery was introduced.
Health Service (SNS) was dismantled
and replaced by a set of private profit- With the return of a civilian, elected
making enterprises (ISAPRES) and the - governmentin 1990, expectations were
creation of the Fondo Nacional de Salud high for an improvement in the health
(FONASA) which manages the health services. However, although health
contact n’146 - December 1995-January 1996
HEALTH WORKERS
expenditure has increased, World Bank- Unfortunately, one can appear on the ~
inspired policies are still being applied. computers as being registered but it
As the crisis in primary health care might not necessarily be true. My sister-
deepens, the poorer municipalities are in-law was able to find work last year
particularly badly affected. Meanwhile, and so she was automatically regis-
the Frei government and other World tered and had to pay for ISAPRES. But
Bank policy advocates continue to speak she lost her job six months later and no
The poor end up
enthusiastically about the health reform longer has access to private services.
lying in order
process in Chile. The voices of those Nevertheless, she appears on their list
to be able to mostaffected by these reforms are rarely of registered clients.
obtain the right heard.
Valeria: The majority of the people are
to receive services. In this interview, Monica Maldonado only recently becoming aware of what.
which are now and Valeria Garcia, health promoters has happened to the health services.
trained by EPES who have lived all their They feel totally vulnerable - as if there
reserved only for
lives in the dusty, urban poblaciones | is no place to turn for help. Part of the
the indigent.
(poor communities) of Santiago, give complexity of this system is that there is
their view of the changes. a new way of classifying poverty. For
example, if you have an iron or a re-
Question: How do people in your
frigerator, you are no longer poor. Th
neighbourhood understand the pri-
poor end up lying in order to be able to
vatization process of the National
obtain the rightto receive services which
Health Service?
are now reserved only for the indigent.
Monica: People understand that with
Question: How were the services
privatization, the possibility of receiving
before the process of privatization
adequate health services has gone.
began?
They are gradually losing what they
used to consider their rights. Monica: Before, the State subsidised
health care through the National Health
For example, in this community, every-
Service. There used to be free prenatal
one has had to re-register at the public
care, dental care, immunization, well-
health clinic. This is because, officially,
baby care, and so on. If you were poor
our community is moving out of poverty.
and needed hospital care, for example,
Supposedly, because such a high per-
you were guaranteed the same rights _
centage of this community is using
and benefits as someone who could
ISAPRES (the private sector), we can
Monica Maldonado showing pay. There was not really a second-
handicrafts which she and no longer be categorised as poor.
class health system for “second-clasj—
other health promoters make to
support their work. citizens as there is now.
Today, we are hearing about things in
our neighbourhood which had not pre-
viously happened for many years. For
example, there have been a couple of
cases of women dying in childbirth inthe
public hospital. That should not happen
in the 20th century. And who responds?
Nobody.
Question: With so many problems ~
from your perspectives, why do you
think the World Bank promotes pri-
vatization as a model of health care ©
for the developing world? |
Valeria: Everything is looked at froman
economic point of view, not fromahuman —
point of view. From my perspective,
EPES privatization is just one more way to line
ve
contact ‘146 - December 1995-January 1996
Pe
HEALTH WORKERS
_ the pockets of the rich. There seems to
_ be a loss of conscientiousness globally
intoef hurmanm lisfe a nd human beings.
Everything is related to money and
consumption. |
Monica: | am worried about who makes
these decisions and based on what
evaluations. When is the voice of the
people most affected by these policies
ever heard and listened to?- Who has
ever asked us what we think of privati-
zation?
When the National Health Service in
Chile began the process of privatiza-
tion, we were living in a dictatorship and
were not informed of the changes. Pub- CAhirdi stian
lic health workers and some sectors of Small girl near her home in an
urban community in Santiago
Be population resisted the privatization longer any sense of service —everything
_ process but they were repressed by the is calculated according to its economic
Pinochet government. Unfortunately, value. The ideals of service and solidar-
because of all today’s one-sided hype ity in this world of consumerism are not
-about the reforms and “modernisation”, valid.
all change is seen as “progress” for the
Part of our problem (with the present
country. We never hear about develop-
approach to providing health services)
ment of people, we only hear about
is that our concept of health is pro-
economic growth.
foundly related to life. Health means
Valeria: Inadequate health care affects having work, education, adequate It has become common
all aspects of people’s lives. Now that so housing, recreation, a clean environ-
to hear of people
many services must be paid for, it has ment, living without fear of government
who have stopped
become common to hear of people who repression, and the possibility of partici-
have stopped eating so that they can pating actively in the policies and pro- eating so that they can
afford to go to the doctor. We all know grammes which affect our lives. With afford to go to the
that this just makes you more vulner- the current privatization schemes, not
doctor.
able to illness. Once people start dying only in health but also in education and
<on the streets then maybe others will sit other services, we are moving farther
up and take notice of whatis really going and farther away from “health for all” —
on. not closer.
Monica: We are all Chileans. We all As members of poor communities, we
contribute to building this country. Having are used to organizing and fighting to
access to adequate public health have our rights recognized. This situa-
services is not asking for a hand-out - it tion is justa new momentin that struggle
is a basic human right and we deserve for us.
it.
Interview by EPES staff members,
Question: Do you think anything can Karen Anderson and Lautaro Lopez,
be done about this situation? who also provided the introduction.
Valeria: The main complaints that peo-
ple have are related to the decreasing
quality of the services. People feel so
humiliated and frustrated by the inhu-
man treatment they receive. Health pro-
fessionals here used to be very con-
scious of the reality of poor families —
now itis all simply economic. There is no
contact n‘146 - December 1995-January 1996
PHC ADMINISTRATOR
\
LETTER FROM CAMEROON
COST RECOVERY CAN WORK!
While many blame the deterioration in a) As a community health initiative, the
the health services on the World Bank’s programmeis self sustaining atv illage
policies, Contact reader in Cameroon, level. It encourages and builds com-
Mrs PA Mitchell of the Life Abundant munity independence in such a way
Programme in Kumbo, was also critical that, should expatriate personnel have
of the position taken by veteran health to leave, itw ould be possiblfeo r health
activist, Dr David Werner. She wrote to care to continue. .
say that contrary to the views he
b) Because the “initiative” to have village
expressed in “The build up to the crisis”,
health care always and only originates ©
Contact 147, February-March 1995, she
with the community, the idea of self
had found that cost recovery could be
funding and self determination is
successfully implemented for the benefit
built-in feature of the programme.
of the poor. Here is herl etteri n response
People therefore understand from the
to Dr Werner's article.
outset that all income to the Health
Dear Dr Werner, Post will be used to benefit the com-
munity. The income covers the costs
| am administrator of the Life Abundant
of salaries, continuing education and
Programme (LAP), acommunity health
the maintenance and improvment of
initiative in Cameroon, West Africa and
equipment of Village Health Workers
| should like to make a few comments
and Trained (traditional) Birth Attend-
regarding your article.
ants. Salary levels of the VHW and
Cost recovery systems TBAs are agreed at the village level.
Our experience at LAP over a 15-year
c) The Village Health Workers and the
deriod has been that cost recovery is an
members of the Village Health Com-
acceptable practice and works well.
TBAs in Rwanda learn to use mittee administer the locally-gener-_
leaves and roots to make ated funds. They are all local people
age-old remedies that work in
and are therefore able to judge with
tandem with modern medicine.
some accuracy those families wh€>
absolutely cannot afford the cost of
needed treatment. In such cases, they
have the right and the resources to
reduce costs or even to waive them
completely if they see fit. However, in
practice this rarely happens. Either
- people are encouraged by the Com-
mittee to pay in instalments, or
- amethodof bartering goods is found
for them, or
- a formal appeal is made to the local
church which may then help. In real- —
ity, this is a less common option not
because the church will not or does
not want to help but because the
people realise that once again this
represents the dependence that they
have tried so hard to avoid.
DBeermtm ers/Unicef
contact n°146 - December 1995-January 1996
PHC ADMINISTRATOR
Nurses distribute drugs at the
Methodist welfare clinic in
La Saline, Port-au-Prince,
Haiti.
Taxation recovery. Only about 30% of salaries
In some countries, the central govern- and costs of these qualified nurses is
ment tax structure does not incorporate met by overseas funding agencies, and
or is not adequate to support Health this figure is decreasing annually in real
Care for All. If health is provided by terms. However, as the programme is
outsiders or local agencies, there is the continuing to develop, there is an
dependency that goes with it. Addition- increase in the overseas contribution in
ally, in the many countries where the direct proportion to the expansion for
system is corrupt, even funds raised to the time being. To-date funding agencies
pay for drugs or treatment is frequently have agreed to underwrite this cost.
‘diverted, and overseas aid salted away
Contrary to what you say in your article,
in private bank accounts before it ever Only about 30% of
the health centres find that as people’s
wren’ those for whom it was intended.
awareness of improved health standards salaries and costs
svhere is therefore no practical alterna-
- increases, so does the utilisation rate of these qualified
tivetosome form of cost recovery system
(UR). This is a finding of this year’s LAP
if health care is to be truly indigenous nurses is met by
Evaluation conducted by Bread for the
and sustainable. overseas funding
World.
Targeting agencies.
Thank you for the clear and concise
In our programme, preference is not
assessment of the Health Care situa-
givenin any particular individual or group.
tion in developing countries and factors
Health care and teaching are offered on
contributing to the difficulties that so
a non-partisan basis to all.
often beset primary health care in these
While the Village Health Workers take countries.
responsibility for maintaining continu- Mrs P A Mitchell SRN RMN
ous teaching and care in their com- LAP Administrator
munities, qualified nurses make support The Life Abundant Programme
visits to their group of posts and conduct PO Box 9, Kumbo, NW Province
vaccination and referral clinics. Funding Cameroon, West Africa
for these visits comes from the larger We forwarded Mrs Mitchell's stimulating
Integrated Health Centres and Hospi- letter to David Werner and asked him to
tals. These bigger centres are also send us a copy of his reply to her.
funded to a large extent through cost Please turn over.
contact n‘146 - December 1995-January 1996
PHC ADMINISTRATOR
The following are extracts from David lective provides a helping hand to its
Werner’s response. individiuna tlimses of hardship orillness.
In some cases, this group or collectivei s
Dear Mrs Mitchell, the extended family, in others the com-
munity, in some cases the district, prov-
Thank you for your letter. Many of your
ince or state. As societies have evolved
points are well taken. You do well to
to large nation states, cost sharing has
emphasithzate i n your health community
become formalised through progressive
programme in Cameroon, cost sharing
taxation. Those who have more are
has been successful and is conductive
asked to help more in ordert o help meet
to self-reliance. To a greater or lesser
the basic needs of those who have less.
extent, this has been true of many self-
This ensures that the maintenance of
determined, non-government grassroots
health is a basic human right.
programmes.
We are all in favour of self-determina-
What needs to be clarified is that “cost
tion and shared responsibility. Certainly,
sharing” can be either benevolent or
each individual and family should be
malign, depending on whether it is initi-
encouraged and helped to take the
ated from the bottom up or imposed
primary responsibility for their own.
from the top down. When itis something
health. But part of that responsibility C2
that a person aspires to, either individu-
In a humane, caring
not just paying for health services. It
ally or collectively, then it can be
society, the larger group potentiating. When it is something also involves joining together in an
organized demand for the social condi-
or collective provides a imposed in order to shirk responsibility,
tions and public services that make
helping hand to its and as a denial of human rights, it can
health and self-reliance possible, not
be oppressive.
individuals in times of just for oneself but for all. To make self-
In a similar experience to your own in
hardship or illness. reliance possible and sustainablfeor all,
Cameroon, | have been involved for
we must be sure that land, wages,
many years in acommunity initiative run
employment and education— and social
by local villagers in the mountains of
guarantees in times of need or emer-
Mexico. For better and for worse, most
gency — are fairly distributed. In a just
of the health care people receive is what
society, people can be asked to pay
they manage to provide or pay for them-
their share of the costs when they are
selves. As in many countries where
assured their share of the gains.
governments administer inadequate
| think that basically there is much we |
basic health services to those in greatest
agree upon. | thank you for your lettez-
need, community-level initiatives must
relating your experience calling on m
do their best. Under such circumstances,
to try to clarity the issue more clearly.
families, neighbours and members of
Keep up the good work.
the community try to help each other
David Werner —
and share costs in times of need. But
HealthWrights
this sort of benevolent “cost sharing” is
Workgroup for People’s Health and
quite different from the current heavy-
Rights
handed global policy of imposing cuts in
964 Hamilton Ave
health budgets, and making poor people
Palo Alto
pay for services that were previously
CA 94301, USA
covered or subsidised by the state.
Worse still, this increased burden on the
poor comes at a time when real wages
are falling, when landlessness and
unemploymentare rising, and when the
gap between rich and poor Is widening.
One way or another, people necessarily
This drawing, which appeared contribute to the costs of health care;
in David Werner’s book
that is to say “cost sharing”. Inahumane,
“Where there is no doctor’,
has become his trademark. caring society, the larger group or col-
8 contact n'146 - December 1995-January 1996 —
PROGRAMME MANAGER
QUESTIONING THE
“ROBIN HOOD” APPROACH
Daleep Mukarji, former general
secretary of Christian Medical
Association of India (CMAI) and
now working with World Council of
Churches, has managed several
major health programmes through
periods of financial crisis. Here he
® describes the difficulties that he
_ faced when he adopted the Robin
Hood* approach of raising money
from the rich to pay for health
services for the poor. He
concludes that if the rich are not to
benefit more than the poor, the
primary objective of community
financing initiatives must be
community involvement and
serving the needs of the poor.
Like many other non-governmental
organizations (NGOs) involvedin health
care, church-related hospital and com-
unity health programmes find it
increasingly necessary to raise funds
and reach some level of self-reliance.
My experience comes from an involve-
ment in a community health and rural
development programme in India in
1970s. We decided that we wanted to
raise funds in the community not only PHaaurlr ison/WHO
because we needed this money but Practitioners of traditional ~
also because we believed that some curative care given at the base hospital medicine have always charged
for their services.
contribution and participation from the and those who could pay and travel to
communitwyas important. People would the hospital benefited most. The poor
value our services if they paid even a did not benefit. They could not take time
small contribution. off to travel to the hospital, and did not
First, we introduced fee-for-service. Our have the funds even to pay for registra-
staff and health volunteers knew the tion. We subsidized essential antenatal
community and therefore were able to and child health services in order to
grade charges, raising more funds from make them more widely available. How- * Robin Hood was an English
those who could afford to pay higher ever, we were still not able to reach the forest outlawin the Middle Ages
who stole from the rich to give
fees. However, the fees only covered whole community. to the poor.
‘contact n’146 - December 1995-January 1996
PROGRAMME MANAGER
WHAT ARE THE INCOME-RAISING OPTIONS?
Community contributions Donor agencies |
- donations from local charitable Itis importantt o be clear from the start
organizations and from churches,
that donors have their own priorities,
local clubs, industry, philanthropists pressures and policy guidelines. Many
and wealthy community members. NGOs have felt forced into
Donations can also be made in kind. programmes designed to fulfil the
fee for services in which payments standards and reporting requirements
are made directly by patients/bene- of donors.
ficiaries for services.
The entrepreneurial approach
prepayment schemes, including .a Some of the tried and tested options
variety of community-based health include:
insurance schemes.
a) Income generating schemes, such:
health tax/community levy is poss- as renting or leasing part of their
ible where all are involvae ddefiinne d land, buildings and equipment in
community and where there is an. order to produce an income.
acceptable community leadership.
b) Soft loans and special assistance
fundraising schemes, such as pub- from banks and financing agencies
lic entertainment shows, lotteries and to pay for profitable ventures.
subscription drives.
_c) Providing health schemes so that
Government grants local industry can offer health
NGOs should avoid becoming overly services to employees.
dependant on their government. It is
d) Endowment funds
also worth remembering that many
NGOs spend much time and money e) Specialised services by hospital
coming to grips with the government and programme staff such as
bureaucracy and then still do not offering training courses and
receive their grants regularly. consultancy.
Governments may also assist NGOs f) Building trustee support among
in obtaining funds and supplies from those who are members of the
Unicef, WHO and other international church, trust or group which owns
agencies. or runs the NGO health project.
Community insurance We had great difficulty explaining the
We therefore initiated a community scheme and persutahe dlocialn pegopl e ©
health insurance scheme with which we of its value. They wanted to see how
hoped to cover the costs of preventive those who joined fared before enrolling
health services. This prepayment health themselves. Many of those who paid
insurance scheme was drawn up in the full fee (US$1) could have afforded
consultation with several community more. When they needed services, they —
leaders. We emphasised that the were not charged. Others, who had not
payment would be voluntary and related paid the contribution, were charged.
to ability to pay and would cover the They tended to be the poor who had no
preventive care of women and children spare cash but were more in need of
below the age of five years. services. We began to feel that we were
10
contact n°146 - December 1995-January 1996 ©