Systems do not have brains: the hidden long term costs of user fees
In 1980s, user fees for health care were introduced without supporting scientific evidence. Thirty years later universal health care is advocated without scientific research of the situation. As a result, unofficial user fees are today worsening gender and health inequality.
The world’s premier global health journal, The Lancet, recently released a special collection of papers exploring the social, political, and economic issues around the global movement towards universal health coverage – an idea whose time appears to have come, or perhaps returned. There were some raised eyebrows, however, over the name of the man who led the Lancet series. It was David de Ferranti, now president of the Results for Development Institute but in the 1980s, a staff member of the World Bank and one of the chief proponents of the introduction of user fees for health care in developing countries.
User fees for health care not only decrease utilization of health services, but also results in delayed presentation for care, incomplete or inadequate care, compromised food security and household financial security, and reduced agency for women in health care decision making. The effects of user fees are amplified by conditions of poverty, as well as gender and health inequality; user fees in turn reinforced the inequalities created by those very conditions.
Even though user fees may now officially be abolished in many developing countries the concept has entered the weak health care systems as a virus. All over Africa and Asia poor patients are now instead faced with unofficial user fees for HIV lab tests and drugs, and tuberculosis treatment. Poor pregnant women are asked to pay unofficial fees if they want an assisted delivery, and even more if they want medications, a bed, a cesarean section or a kit for cleaning the umbilical cord. And user fees are a poverty booster: the poorer a TB patient is, the more they are likely to be presented with an unofficial, illegal user fee for their treatment. User fees may well turn out to be the biggest single risk factor for child mortality in Sub Saharan Africa – but no one dares to do this unpleasant calculation.
The same international institutions that in the 1980s without any scientific evidence introduced user fees to the defenseless fragile health care systems in Africa now 30 years later advocate their abolishment. The problem is that just as they didn’t do their homework when they introduced the concept in the 1980s they are promoting the idea of Universal Health Coverage without any idea of the long term hidden consequences of user fees and how this will tamper with their latest fashion in health. Systems do not have brains. That is why we need the Global Health Minders: a think network that can act as a surrogate brain for the international global health community by suggesting and supporting a more sustainable way for global health based on experience, evidence and a broader, more long term view on health effects of proposed interventions.