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Submitted by Bob Yates on
Yes I would be delighted to contribute to your next piece on user fees and might I suggest that you also consult policymakers in developing countries, because I am concerned that what you are advocating is going against global trends. Rather than increasing the role of private voluntary financing of heath care (including for medicines) the trend across the developing world is for governments to socialize health financing, both in terms of raising revenues and purchasing of services. This is because publicly organized financing systems (but not necessarily service providers) are more efficient and equitable than private systems, which leave purchasing decisions to individual health care consumers. I don’t doubt that currently many poor people bypass inadequately financed public health providers for fee charging providers particularly when the former lack essential medicines. This is perfectly rational behavior. But given the huge information asymmetry between providers and purchasers, patients are extremely vulnerable to being ripped off in the private market. I know this from a recent experience when a family member was charged $130 by a doctor for 3 medicines to treat a throat infection and even then the wrong antibiotic was prescribed. Will poor people given additional purchasing power with vouchers or additional cash fare any better? Recognising these inherent market failures countries across the globe are trying to take the financial incentives out of prescribing medicines and diagnostic tests. This has happened in countries across Latin America (most famously in Brazil and Mexico), Asia (Malaysia, Thailand, Nepal, Sri Lanka) and increasingly in Africa too (South Africa, Ghana and many countries now providing free care to pregnant women and children) . China is a fascinating example of a country which previously had a publicly financed system, allowed private medical sales to take over and is now re-socialising its financing system with the specific objective of removing financial incentives to oversupply medicines Furthermore learning from all these lessons India is about to launch its UHC reforms with a massive initiative to provide free generic medicines to all citizens. All these countries have recognized that the health care market is different to other markets for goods and services and requires strong state intervention to protect consumers and ensure that the healthy wealthy cross-subsidise the sicker poor. Increasingly Governments are therefore looking to replace inefficient and inequitable private voluntary financing with compulsory, pre-paid, public mechanisms such as tax revenues and social insurance contributions. For all the countries mentioned above plus the whole of the OECD (with one glaring exception) this is proving to be the key to achieving universal health coverage.