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Submitted by Ms. Nisha Agrawal on
My colleagues at Oxfam and I were appalled to read this post advocating for user fees for essential medicines -- and other essential health services -- in developing countries. The blog ignores the large and growing body of evidence that these "out of pocket" fees block access to health services, especially for the poor and for women, and overlooks evidence that it is extremely difficult to target the poor effectively with subsidies or vouchers. In fact, new research from the Lancet shows that no country has achieved universal health coverage so long as the health system relies predominantly on out-of-pocket payments. In India, evidence from across the country shows that the poor are affected disproportionately by user fees. The Common Review Mission of the National Rural Health Mission found that in specific states like Madhya Pradesh and Chhattisgarh, only 2.47% of patients were exempted from charges for services on the basis of "Below Poverty Line" (BPL) status, although the BPL proportion of the population is 37%. On the other hand, a simulation analysis of 20 African countries published in the British Medical Journal in 2005 calculated that the abolition of user fees could prevent approximately 233,000 under-5 child deaths annually. And there is ample evidence from Africa showing a substantial increase in utilization of services after fees were abolished, including in the 12 countries that have abolished fees for maternal and/or child health over the last decade. The blog also presents various ideological and ill-supported claims as facts, tying the use of public health financing to doctor incompetence and lack of effort, and to health worker absenteeism. It also makes the argument that people use medicines (and other health services) frivolously when these are offered free of charge. There is little evidence to show that user fees prevent frivolous demand. Rather, user fees have been an ineffective, inefficient and inequitable financing mechanism that, in the words of WHO's Margaret Chan, have "punished the poor." This blog takes us back 25 years, to the days when the Bank was pushing user fees in developing countries, with disastrous consequences for the world's poorest people. The World Bank has moved on from those days. Its current Health, Nutrition and Population strategy says the Bank will support interested countries to remove user fees (although it puts up too many obstacles to providing that support, such as already having financing and planning in place), and the Bank has done fantastic work in some countries, such as in Sierra Leone where it recently supported a promising program to remove fees for maternal and child health, which is seeing early success. Furthermore, President Kim made a speech at the UN last month in which he acknowledged that high out-of-pocket healthcare expenditures are among the leading causes of poverty. So what is the Bank's real policy on this issue? Nisha Agrawal Executive Director Oxfam India