Providing free health care more complex than usually thought

Over the last years, many low and middle-income countries have removed user fees in their health care sector. Researchers from Africa, Asia, Northern America and Europe have studied these policies; their findings are gathered in a supplement of the scientific journal Health Policy & Planning, coordinated by Bruno Meesen from the Antwerp Institute of Tropical medicine. Experiences from Afghanistan, Burundi, Burkina Faso, Mali, Nepal , Rwanda and Uganda, among others, are documented in this supplement. Conclusion: it is possible, but should not be done ill-advised.

The main lessons from their analyses are the following ones:

• These policies are often decisions taken by the highest country authorities; sometimes during electoral campaigns
• Many countries are opting for selective free health care (e.g. free health care for children under 5, free delivery). This allows a good alignment on the Millennium Development Goals and is probably reasonable, given the costs of free health care policies.
• When these decisions are taken in a hasty manner without sufficient consultation of stakeholders (including technicians working for the concerned ministries), health systems may experience a shock (difficulty to cope with the increase in patients; drug shortages).
• When these policies are well-designed, implemented with the appropriate accompanying measures and sufficiently funded, they can improve access to health services. Insufficient funding may however imply that the increased utilisation by the population paradoxically leads households to spend more for their treatment (for instance, because of drug shortages in free public health facilities, households may have to buy their drugs in private pharmacies).
• There are different ways to reduce financial barriers to health care; free health care is an option, health insurance is another. Any good solution - for the vulnerable populations and the public budget - will require a certain level of complexity. It is therefore important that leaders consult their technicians; the latter can help the former to build fair, efficient and sustainable health care systems.
• Donors, aid agencies and Northern Non-Governmental Organizations have a role to play, but in full respect of sovereign choices made by low-income countries.

According to Bruno Meessen, researcher at the Institute of Tropical Medicine and coordinator of the supplement, "Leadership developed by African leaders in favour of vulnerable populations such as young children and pregnant women has to be praised. Good outcomes for these groups however require a long term commitment in terms of public resources and policies which are sound from a technical perspective. Providing free health care is more complex than it is usually thought."

Lucy Gilson, Professor at the London School of Hygiene & Tropical Medicine and at the University of Cape Town and co-editor of the supplement says: "As leaders take important decisions to strengthen health systems for the benefit of the poorest, their engagement with communities, health workers and technicians is vital in bringing those decisions alive in the day to day practice of health care delivery".

Abdelmajid Tibouti of UNICEF New York "hopes that this supplement sponsored by UNICEF will be a source of inspiration for governments and their partners. Equity is a major challenge in many countries. Technical and financial partners have probably a stronger support role to play, in full respect of course of options chosen by countries themselves. A first track is to network countries implementing similar policies."

In this respect, Bruno Meessen sees very positive trends. "African experts working on these issues are organised themselves in a community of practice. Thanks to information & communication technology, they constantly share their experience and knowledge. Opportunities to learn from each other are many."