The Ivorian health ministry is reviewing its policy of charging fees for health services, hearing recommendations from UN agencies, aid groups and other experts on potential changes to the 10-year-old system.

The effort comes as aid organisations are lobbying the government to provide free health care, at least to some at-risk groups.

The government is “evaluating the health cost recovery system, in place since 1996, to see what has worked and what has not,” N’da K. Simeon, head of communications at the Ministry of Public Health and Hygiene, told IRIN. But he said the evaluation is not linked to a debate swirling in Côte d’Ivoire over the merits of free access, saying it is simply time to take stock of a policy that has existed for more than a decade.

Health experts worldwide have long debated the merits of free health care, with some proponents saying that fees deprive masses of people of basic services. Opponents of free access argue that making patients pay fosters community participation in health care and is necessary for the upkeep of the staff and facilities that make up the public health system.

The Ivorian health ministry has invited representatives of UN agencies and non-governmental organisations, as well as other experts, to a 27 to 29 August meeting to air recommendations and study the issue, N’da said. The gathering is to include medical officials from around the country.

Objectives of the seminar include “to take stock” of Côte d’Ivoire’s health cost recovery policy and to “reflect on opportunities for a revision of the tariff scale for health services”, according to a health ministry document laying out the meeting's agenda, obtained by IRIN.

The document says: “We have seen a certain malfunction in the execution of cost recovery for health services” – notably inconsistency in tariffs and medical supply problems in some health facilities. The document adds that some communities “find that health services bestowed to them are too costly.”

Aid groups weigh in

The health ministry’s evaluation comes as aid workers are trying to convince the government to adopt a policy of free health care, at least for some vulnerable groups such as children under a certain age or people with malnutrition.

Unaccustomed to humanitarian crises, Côte d’Ivoire saw an influx of aid groups after a rebellion and brief civil war in 2002-03. Now, as the country creeps toward peace, it is working to revitalise health and education infrastructure particularly in the north and west, a goal that has been complicated by an exodus of state workers to the government-controlled south when rebels occupied the north.

The debate over free health care came to the fore this year when Médecins Sans Frontières ended its work at state hospitals in Bouake and Man, where for about four years it provided free health services. MSF said in a recent internal report that it hopes the Ivorian health ministry and external donors will continue to support public health facilities “for a population still heavily affected by the crisis”.

At the Bouake and Man hospitals, where MSF had worked until May and July respectively, health services are still free pending a health ministry decision. The government cannot impose "a brutal rupture" on communities that got used to free care, the health ministry's N'da told IRIN.

Free for certain groups

Save the Children UK (SC-UK), which provides free medicines to children under five and pregnant women in western Côte d’Ivoire, is another group that plans to weigh in on the government’s health fees policy.

“Our global position is that health care should be free at the point of access,” SC-UK country director Heather Kerr told IRIN. “We’d like to see that for everyone,” she said, but added that since the Ivorian government does not appear ready to adopt such a comprehensive change, SC-UK will likely push for free care for certain groups. “We have to find a target group or a target area – it’s difficult [in Côte d’Ivoire today] to define who’s vulnerable.”

Vulnerable groups that UN agencies would like to see receive free care are those suffering malnutrition, according to Chouahibou Nchamoun, a nutrition specialist at the UN Children's Fund (UNICEF) in Côte d'Ivoire. UNICEF goes along with government policy and does not take a position on health cost recovery in the country, but it has joined with the World Health Organization and World Food Programme in a joint recommendation of free care for people with "severe acute malnutrition", Nchamoun said.

The World Bank, which funds recovery and development projects in Côte d'Ivoire, says it is ready to back a system of free health services. "The World Bank believes that poor people should not have to pay for access to basic healthcare services,” Phil Hay, spokesman for the World Bank’s human development department in Washington D.C., said. “Ultimately it's up to developing country governments to decide their own financial policies around healthcare, but the Bank stands ready to help governments which do abolish user fees for health, to find other sources of finance to make up for the revenue they lose from doing away with fees.”