West African governments considering lifting health care fees for all will soon have a guide to manage the financial impact of the move.

The guide, which the NGO Save the Children expects to launch in November, will show policymakers in developing countries how to estimate resource needs that may arise from abolishing fees.

Groups campaigning for free care for all say even minimal fees can be deadly when they cut off millions of the world’s poorest from lifesaving basic care, while contributing only a small portion to health sector revenue.

But how to lift fees and sustain a health care system remains complicated. “[Countries] do not have the tools to plan for such a policy change and its implementation,” Alice Schmidt, health advocacy adviser with Save the Children, told IRIN.

The five steps in the guide, “Freeing up Healthcare”, are: analyse starting position, estimate how removing fees will affect service utilisation, estimate additional requirements for human resources and drugs, mobilise additional funding and communicate the policy change.

In many West African countries, governments, civil society groups and local and international NGOs are studying how cash-strapped countries with poor health infrastructure – some recovering from years of conflict – can ensure basic health care for all.

In Sierra Leone a health financing task force with representatives of the government and NGOs has been studying the issue for months. The government is looking at options for financing health care; for now, public health care is free only for some groups, including under-five children and pregnant and lactating women.

Nothing less than free

The UK’s Department for International Development (DFID) supports the removal of user fees.

The World Bank in its 2007 health strategy said it “stands ready to support countries that want to remove user fees from public facilities,” if the lost resources can be replaced for effective functioning of the health system and if resources go to providing quality services for the poor.

But NGOs say donors must go further, telling governments they will support them in lifting health care fees.

“The evidence that abolishing user fees improves access to health is completely overwhelming,” Anna Marriott, health policy adviser with Oxfam-Great Britain, told IRIN. “User fees block access to health care for millions of people.”

Free, but not for all

The UN’s Children’s Fund (UNICEF), while supporting universal access to health services, does not believe that simply abolishing health care fees everywhere at a stroke is appropriate.

“In many countries where the health system works relatively well, people are already used to paying for care,” said Celestino Costa, health policy adviser at UNICEF’s West Africa office. “Coming in and just saying we’re going to remove all user fees would disrupt the system. In these cases it is worth a look into the best option to ensure that poor and vulnerable are not left out.”

But some anti-fee NGOs say eradication is the only way to go.

“Free health care is critical for children's health,” said Oxfam’s Marriott. “Rather than focusing only on the problems countries face removing user fees, UNICEF should be actively supporting their abolition.”

UNICEF’s Costa said the agency “stands ready to help governments who wish to exempt certain vulnerable groups from health fees,” saying the decision rests with governments. “The most important thing is to see what measures can be put in place, working with the government, to ensure that the poorest groups get full access to proper health care.” He concluded, “It is a complex question, and it depends on the reality on the ground in each country.”

Health experts backing free care said a September 2008 Médecins Sans Frontières (MSF) report on malaria concluding that free malaria testing and treatment has dramatically increased the number of people seeking care and surviving is further evidence to cut out user fees.
“Getting malaria drugs into a country is not sufficient,” Seco Gerard, MSF analysis and advocacy adviser, told IRIN. “Access is mostly about cost.”

Gerard said in many settings requiring even a small fee for health services forces an “impossible choice” on families. “It’s so easy to treat malaria. That’s why it’s so revolting to hear the numbers of people, especially children, still dying of malaria.”

Health experts stress that while fees present one barrier, many others remain, such as a lack of equipment and medicines in public health centres and a lack of facilities for remote communities.

Sticking with health fees

In Côte d’Ivoire the government studied the question in 2007, and decided to continue charging fees.

“The government is not considering free health care,” Simeon N’da, communications officer with the Ministry of Health and Public Hygiene, told IRIN. “The government subsidises health care and medicines; the fees citizens pay are minimal”, he said, adding that the revenue helps maintain public health facilities.

Some communities in Cote d’Ivoire have enjoyed free health care at MSF hospitals, which came in when the 2002 rebellion sparked widespread unrest and displacement. But MSF is gradually moving out and the adjustment demonstrates some of the challenges of public health care particularly in West Africa’s many post-conflict countries.

IRIN