International Activity Report 2004
No cash, no care
MSF's confrontation with cost recovery
By Mit Philips M.D., MscPH.
Analyst Access to Health Care Research Unit, Brussels

" I was very worried and I brought my little girl to the health center in my district in the south of Bujumbura. But the nurse wouldn't see us as I didn't have any money to pay for the consultation. So I had to take my girl back home without having received any care. Then I had no choice but to borrow 2,000 francs (about euro 2) from my neighbors for the consultation. I also bought a few medicines on the black market. Every day I pay back 150 of the 250 that I earn each day from carrying bags for people. I have 100 francs left to feed my family. It's not a lot." – Simeon, an unemployed man who brought his three-year-old daughter suffering from second-degree burns to an MSF health clinic in Burundi

Simeon's situation is a common one. A recent MSF survey done in 2,700 households throughout rural Burundi revealed that almost one in five people did not receive medical care the last time they were ill. The main reason for that was a lack of money. While the cost of a basic consultation might not seem excessive: approximately two to three euros, the average Burundian has to work for 12 days to earn this amount. Although theoretically the poorest patients are exempt from paying, in reality, less than one percent actually does not have to pay. The survey also found no correlation between a payment exemption and extreme vulnerability. Among those who did attend a health clinic, the vast majority had to borrow money or sell some goods to pay the medical bill, feeding the vicious circle of illness and poverty.

In Burundi, this situation is the consequence of a government edict issued two years ago that led to the liberal use of user fees in primary health care. The introduction of cost recovery was not so much a new health policy, but rather the activation of part of the planned health sector reform that had remained dormant since the 1990s.

With civil conflict ending and peace negotiations progressing, the country's emergency phase seemed to be coming to an end and donors wanted to move from relief to development aid.

As a result, people who could not obtain medical assistance for years because of insecurity are now excluded from care because of their inability to pay for it. Currently Burundi is listed as one of the world's three poorest countries. About 99 percent of its population lives on less than US$1 per day, and a staggering 85 to 90 percent lives on less than US$1 per week. Nevertheless, if nothing changes, health care will remain available only to those who can afford it, keeping it out of reach for almost a million people.

" My wife died a few months ago. Very probably from malaria because she had a lot of fever and was also vomiting. But she never went to a health center. Because of the lack of money. I don't even have enough to feed my two children so how could I have paid the price of a consultation? I thought that she would eventually get better. That didn't happen. After four months in that state, she finally died." – – Révérien, an unemployed Burundian man, living on the outskirts of Bujumbura

User fees in the real world

Today, user fees are an increasing part of the environment in which MSF works. Due to failing state funding, user fees have become the cornerstone of public health care financing in many countries. Implemented without any effective solidarity measures, they are a barrier for the patient and a major constraint for MSF. In many places, MSF has been pressured by governments to introduce user fees, even in complex emergencies. For example, in poverty- stricken southern Sudan, user fees were introduced in 2003 as part of a USsponsored health program. Health centers supported by MSF were forced by authorities to ask patients for money in exchange for care. The result was immediate: attendance rates plummeted. In particular, women and children stopped coming to the centers for help.

Beyond emergency situations, people also need access to effective care. Poor people are particularly vulnerable and the major part of the disease burden is concentrated among the poor. In low-income countries, the poor do not constitute a fringe part of the population – poverty affects the vast majority of the people. The exclusion caused by user fees implies that it has become increasingly difficult to reach the poor through existing health services. Besides ethical considerations, this raises questions of accountability for any agency serious about reaching its beneficiaries.

Moreover, out-of-pocket expenses for health care pose a serious risk for further impoverishment. Medical expenses cause poverty. How can we accept the fact that poor people in poor countries are asked to pay a greater share out-of-pocket for health care than people in high-income countries? While some countries are implementing cost recovery systems at a rapid rate, others are dismantling them to remove barriers to care. Recent examples from countries that are working to abolish user fees show spectacular increases in attendance rates. In South Africa, for example, use of curative services doubled when fees were no longer requested. In Uganda, consultations saw a 120 percent increase in the months after fees were stopped. And interestingly, more people took advantage of preventive care including vaccinations, although they were already free. MSF has experienced similar increases when user fees were stopped in the places its teams worked. During the recent crisis in Cote d'Ivoire, attendance rates rose significantly when consultations became free, leading to commentaries that the emergency situation was improving access to health care! A similar tendency was noticed by MSF in Liberia and Sierra Leone.

However, in most countries, our teams face a great deal of resistance to the idea of free medical care, even when MSF agrees to subsidize all of the involved costs. Often the ministry of health is reluctant to give permission for MSF to provide free care, as it relies on user fees to pay functioning costs in the absence of central funding. Free essential care means higher utilization rates, which is good news from a medical point of view, but which brings higher costs with it.

Taking a stand against user fees

Over the years, MSF teams have struggled with the user fee issue as MSF had to work within or around the existing system. In some projects, attempts were made to improve cost recovery systems, focusing on rationalizing care-seeking, moving to more effective waiver systems and making better use of collected revenues. Sometimes MSF teams saw user fees as a necessary condition to be able to operate within a country. However, based on disappointing experiences and serious self-critique, MSF is now strengthening its opposition to user fees. Humanitarian assistance, by definition, helps the most vulnerable. That help should be organized in a way that makes it as accessible as possible. With that in mind, how can MSF participate in a system that accepts exclusion from essential health care for the sake of sustainability, efficiency or other benefits for part of the population? In 2004, MSF decided that as a humanitarian association dedicated to assisting people in times of crisis and targeting the most vulnerable, we could no longer accept or allow exclusion within our projects.

Currently, MSF is in the process of implementing a policy whereby the health care we provide is free at the point of delivery in conf lict contexts. The crucial issue is that people in crisis should not be forced to choose between spending scarce resources on health care or going without it. In postconf lict or stable contexts as well, MSF's starting position will be that health care in our programs should be free at the point of delivery.

Changing our position is not easy or cheap. In many countries, MSF will have to challenge state or donor agency policies that result in the exclusion of the most vulnerable. Providing free care to patients will also imply that extra financial resources are necessary, not only to compensate the loss of income from the fees, but also to face the increased demand. MSF is committed to ensure free medical care for patients in its projects. But is this enough?

MSF's confrontation with macroeconomics

In a context of deficit health budgets and pressure from international agencies such as the International Monetary Fund and the World Bank to restrain public spending, health services are doomed to focus on making ends meet instead of responding to the needs of the ill.

Does it make sense for MSF to provide free health care to its own patients, without advocating for it for vulnerable populations we don't reach? Should MSF go further and advocate for a whole new health development paradigm? One that allows sufficient public health expenditure? Probably not. Does it make sense for MSF to advocate for more effective (but also more expensive) treatment regimes like artemisinin-based combination therapy (ACT) for malaria patients or antiretrovirals (ARVs) for HIVpositive patients, without advocating for such a new health development paradigm? Probably not. On the other hand, is it our role to become involved in this highly political debate, where so many other actors are already trying to inf luence the policies of the international financial institutions?

Can MSF make a difference?

It could be a logical step for MSF now to promote better access to health care. Through its success in lowering prices for essential drugs in poor nations, MSF's Campaign for Access to Essential Medicines has challenged the inevitability of poor people's exclusion from life-saving drugs. However, maintaining user fees and health budget ceilings will keep even these lowered prices out of reach for large numbers of patients.

Cost recovery policies need to be changed so that lives are not sacrificed for the sake of macroeconomic theory. MSF could play a significant role in showing donor agencies, policy makers and health care providers the true, cruel consequences of their choices. By challenging their declarations of good intent, MSF could insist on transforming existing policies so that they improve people's health and lives, instead of causing further suffering. At least the choice to sacrifice thousands of people should be recognized as such and publicly debated. MSF believes a person's needs should again be central to the provision of health care, not a person's ability to pay. In this way, refusing user fees in MSF's own projects could be a first but necessary step to promote a crucial policy change.