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Taxing the ill - How user fees are blocking universal health coverage
by Médecins Sans Frontières/Doctors without Borders
11:25am 10th Dec, 2017
Dec. 2017
Taxing the ill - How user fees are blocking universal health coverage
Direct payments by patients at the point of health care delivery, commonly known as user fees, lead to low utilisation or exclusion of health care services on offer, difficult assessment of health needs and epidemic risks, and impoverish entire households. Vulnerable groups are particularly affected.
Over the past decade, many countries transitioned away from their user fee policies in favour of free health care initiatives for all or for specific population groups, such as pregnant women, children, and people with certain illnesses.
Considering there is a worldwide commitment to achieve Universal Health Coverage (UHC) by 2030, including “financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all”, one would expect free health care to be at the core of UHC policies.
However, the reality witnessed by Médecins Sans Frontières (MSF) teams starkly contrasts the discourse around UHC. Instead of improved access to care, MSF sees a striking trend towards:
The reintroduction of user fees and other direct payments by patients within national health financing strategies.
A reduction in the commitment and protection of previously accepted fee exemptions, such as those devised for: populations affected by conflict, epidemics, or other crises.
Patients with the need for (life) long, uninterrupted, or repeated treatment and key priority health services, such as treatment for HIV, tuberculosis (TB), malaria, and maternal and child care.
A lack of commitment and support to implement free care policies that secure financial access and ensure sufficient and impactful coverage for the population’s health needs.
In most cases, the proposed policy changes coincide with the expected or announced reduction of international funds for health and a push for domestic resource mobilisation to finance the health sector.
This discourse currently dominates global health policies, despite many governments lacking the resources or capacity to deliver services at the pace required without continued international support. Failure to provide this is likely to undermine previous achievements and delay progress towards UHC.
There is overwhelming evidence demonstrating that user fees in low resource and/or conflict and crisis settings exclude and deter people from seeking care, negatively affect quality of services, and exacerbate poverty and the disease burden.
Indeed, these findings are mirrored by MSF’s experiences in the field and will be exemplified through several case studies. Yet, concrete measures to mitigate the negative effects of user fees are not receiving the attention they deserve in current UHC plans.
If the global health community is serious about making UHC a reality and ‘leave no one behind’, removal of user fees for essential drugs and services must be tackled as a priority. Without that first and foremost step, patients with the greatest medical needs will continue to lack access to essential health care and suffer financial distress.
8 ways user fees for health are harmful to people
When people simply don’t have the means to pay either formal or informal healthcare fees, they are de facto excluded or delayed from receiving care and aren’t treated in time. This can lead to death or complication from treatable diseases such as malaria and can happen even when seemingly small amounts are requested.
Reality check: In the Democratic Republic of Congo, a 2017 MSF population survey in the health zone of Bili, northern Ubangi showed that in a quarter of cases of illness preceding death, no care was sought. Of these, 27 per cent were attributed to a lack of money.
People receive sub-standard or incomplete treatments
When drugs and treatment are unaffordable, people may get less effective treatments or not the full package of care they need.
Reality check: At a health centre in Malawi, some mothers receive only half of the pills needed to treat their children for malaria as they are unable to pay the full amount (equivalent to 9 USD), thereby putting the children’s lives at risk.
Prevention of diseases is reduced
When people are asked to pay for prevention services such as vaccination or screening tests, they are more likely to opt out, putting themselves or others in danger, especially if they carry communicable diseases.
Reality check: In Central African Republic, a pregnant woman is asked to pay the equivalent of 2.7 US dollar for an HIV test but she can’t afford it.
Treatment for disease requiring care over an extended period of time becomes more complex and, ultimately, more expensive
Patients who need (life) long, uninterrupted, or repeated treatment and key priority health services, such as treatment for HIV, tuberculosis (TB), malaria, and maternal and child care dropping out of care because of the recurrent costs.
Reality check: Close to one in four HIV patients hospitalised in the MSF-supported hospital wards in Kinshasa die because the illness is too advanced by the time patients seek care. Over half of these patients were previously on treatment but interrupted it, with a lack of money as one of the main reasons.
People become poorer
There are countless examples of people having to borrow money or sell belongings in order to pay for healthcare, impoverishing their entire family.
Reality check: In a study undertaken by MSF in five districts in Afghanistan, 44 per cent of people who sought care had to borrow money or sell some belongings to get treated.
Patients are kept imprisoned in health facilities until they pay
As absurd as this may sound, there are countless examples of people who are kept captive in health facilities until they have paid the fees they owe.
In a rural area of DRC, a mother and her baby are not allowed to leave the hospital until they pay 38 USD for an emergency caesarean that saved their lives.
Epidemics go unnoticed or underreported, delaying response
When people decide not to seek care or to delay their visit to health centres, it increases the risk of expansion and continued disease transmission in communities.
Reality check: During the recent Ebola outbreak in Likati, DRC (August 2017), the introduction of free healthcare by health authorities led to an increase in outpatient consultations and hospital admissions, which in turn enabled better detection of suspected cases.
It’s more difficult for vulnerable groups to access health services
Vulnerable groups such as the elderly, the poor, refugees and women and children will usually be most affected by user fees as they have less access to services, less means or less rights.
Reality check: A refugee in Jordan stopped treatment for her non-communicable disease because she can’t afford the fees (23 US dollar per consultation).

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