As Côte d’Ivoire's peace process creeps forward and emergency health care providers start withdrawing, the government is beginning to provide medical care again and that will mean reintroducing fees.

“[In conflict zones] communities benefited from free health care,” Jean Denoman, deputy director general at the Ministry of Health, told IRIN. “Now the communities will have a difficult time paying.”  

For proponents of universal free health care a return to full health care costs will penalise the poor. The World Bank and some donors have long argued the merits of user fees for basic health and education, while many aid groups argue that user fees deprive a major portion of the population of basic services and severely diminish standards of living.

In public hospitals in Man and Bouaké, Médecins Sans Frontières began providing free health care services after rebels took over the cities in 2002 and government-paid doctors and nurses fled for their lives. 

But with efforts toward peace advancing, health workers have started returning to the region. MSF pulled out of Bouaké public hospital in May and the Man public hospital in July. 

“With the withdrawal of MSF, clearly the Ivorian government has the problem of financing the central hospitals of Bouaké and Man,” top Health Ministry official Denoman said. “Now the question is: Shall we let these hospitals function without the public’s participation? Clearly that would ruin these facilities,” he said.

''...We cannot bring free health services to an abrupt halt...''
So far the administrations at the two government hospitals continue to provide health services and medicines for free but that cannot last for long, Kouie Jean Plo, head of the Bouaké hospital, told IRIN. “We are awaiting word from the ministries of health and finance on when and how to reintroduce fees.”
He said it is imperative that the government resume fees gradually. “We cannot bring free health services to an abrupt halt,” he said.
Denoman said that fees may start out at a 50-percent discount “then move progressively toward full costs”. 

MSF concerns

The head of MSF-Belgium in Cote d’Ivoire, Christophe Vavasseur, expressed concern that the government plans to return to a full cost recovery system by 2008. “This will exclude a large percentage of the population." 

Health care fees “lead to exclusion”, he said. “This has been well documented and our experience in Man confirms it.” 

In Man treatment for severe malaria can cost more than two months’ average income, according an unpublished MSF report. A Caesarean section costs eight months’ income. 

Vavasseur said health fees also diminish the public’s use of health services. MSF found that in 2006, the number of consultations in four facilities in the west, where it provided free services, were 20 percent higher than the number of consultations in all the 79 centres in the region before the war when people used to pay. 

“We [at MSF] try as much as possible to provide the data to point out that the real need is revealed by free health care,” he said. 

MSF says governments need to keep health costs to a minimum in part by increasing the percentage of their budgets for health services. “We hope the Health Ministry and external donors will be able to continue to support public institutions for a population still heavily affected by the crisis,” MSF said in the paper.

Vavasseur argues that when hospitals become dependent on patients’ fees they fail to seek other financing mechanisms. “In many countries people stick to this way of thinking that people must pay. They think that people must participate in their health care, and that this way [the health system] will become sustainable. But this is not the case. It can even be counterproductive.”