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PubMed2006

To retain or remove user fees?: reflections on the current debate in low- and middle-income countries.

Many low- and middle-income countries continue to search for better ways of financing their health systems. Common to many of these systems are problems of inadequate resource mobilisation, as well as inefficient and inequitable use of existing resources. The poor and other vulnerable groups who need healthcare the most are also the most affected by these shortcomings. In particular, these groups have a high reliance on user fees and other out-of-pocket expenditures on health which are both impoverishing and provide a financial barrier to care. It is within this context, and in light of recent policy initiatives on user fee removal, that a debate on the role of user fees in health financing systems has recently returned. This paper provides some reflections on the recent user fees debate, drawing from the evidence presented and subsequent discussions at a recent UNICEF consultation on user fees in the health sector, and relates the debate to the wider issue of access to adequate healthcare. It is argued that, from the wealth of evidence on user fees and other health system reforms, a broad consensus is emerging. First, user fees are an important barrier to accessing health services, especially for poor people. They also negatively impact on adherence to long-term expensive treatments. However, this is offset to some extent by potentially positive impacts on quality. Secondly, user fees are not the only barrier that the poor face. As well as other cost barriers, a number of quality, information and cultural barriers must also be overcome before the poor can access adequate health services. Thirdly, initial evidence on fee abolition in Uganda suggests that this policy has improved access to outpatient services for the poor. For this to be sustainable and effective in reaching the poor, fee removal needs to be part of a broader package of reforms that includes increased budgets to offset lost fee revenue (as was the case in Uganda). Fourthly, implementation matters: if fees are to be abolished, this needs clear communication with a broad stakeholder buy-in, careful monitoring to ensure that official fees are not replaced by informal fees, and appropriate management of the alternative financing mechanisms that are replacing user fees. Fifthly, context is crucial. For instance, immediate fee removal in Cambodia would be inappropriate, given that fees replaced irregular and often high informal fees. In this context, equity funds and eventual expansion of health insurance are perhaps more viable policy options. Conversely, in countries where user fees have had significant adverse effects on access and generated only limited benefits, fee abolition is probably a more attractive policy option. Removing user fees has the potential to improve access to health services, especially for the poor, but it is not appropriate in all contexts. Analysis should move on from broad evaluations of user fees towards exploring how best to dismantle the multiple barriers to access in specific contexts.

Community Health Services↗
PubMedDate not supplied

[A study on the establishment of a fee system for hospital based home nursing care].

This study was done in order to provide basic data to a Fee System for hospital based Home Health Care services in Korea in the future. It was done by investigating activities provided to possible Home Health Care clients who could be discharged early from general hospitals and then estimating the nursing care fee according to each nursing activity based upon the time used for activity. The subjects of the study were selected by convenience sampling and consisted of 35 clients who might be clients for Home Nursing Care and were presently admitted to a medical-surgical ward of Y University Medical Center located in Seoul, Korea. The data collection period was from September 1, 1991 to September 30, 1991. The research instruments utilized for the study were a client selection criteria for Home Health Care developed by Choo (1991) and a check-list of nursing activity developed by researcher. The results of the study were as follows: 1. There were 44 different nursing activities provided in the seven days but the time was calculated for only 25 of the nursing activities. 2. Fees for the 25 different nursing activities were calculated by multiplying the median of the average wage of a staff nurse having five years experience in an A grade general hospital to the time of the nursing activity. The results were compared with the insurance fee which the government recognized as an appropriate fee for that activity. The nursing activities with a lower calculated fee than the insurance fee were suction, catheterization, exercise education and dressing change. The nursing activities with a higher calculated fee than the government recognized fee were IM injection and vital sign check. 3. There was a range of 1-15 nursing activities provided daily to the client. For the average number of nursing activities per day of 6.26 events the nursing care fee was calculated at W 6136 per day. 4. Based upon the results of the study, a recommendation for a Home Health Care fee per visit based on the nursing activities provided could be formulated for a Home Health Care fee system. It could be formulated as following: 1) Home health Care fee per visit = [(direct nursing fee (direct nursing care time per activity x average nursing wage) + indirect nursing fee) x average nursing activity per visit] + management fee+materials fee+a travel fee. In this way a nursing fee could be calculated based upon the result of the study of the nursing fees per visit.(ABSTRACT TRUNCATED AT 400 WORDS)

Home Care Services↗
PubMed2001

The effects of different kinds of user fees on prescribing quality in rural Nepal.

This study evaluated the effects of three different kinds of user fee on the quality of prescribing in rural Nepal. Using data from 33 public health facilities, we performed a controlled before-and-after study, comparing a fee per prescription (covering all drugs in whatever amounts) against one- and two-band fees per drug item (covering a full course of treatment for each item). With the one-band item fee, each item incurred the same fee; with the two-band item fee, more expensive items incurred a higher fee and cheaper ones a lower fee. Thirteen indicators of prescribing quality were evaluated based on an average of 400 prescribing episodes per facility per year. The percentage of prescriptions conforming to standard treatment guidelines was 12% (95% confidence interval [CI] 3% to 21%) and 15% (95% CI 6% to 24%) greater with the one- and two-band item fees, respectively, than with the fee per prescription. Prescribing quality improved through a reduction in the number of unnecessary, but not necessary, drug items prescribed per patient. Item-based fees are associated with significantly better prescribing quality than a fee per prescription; therefore, item-based fees are preferred over a fee per prescription when considering methods of cost recovery.

Drug Utilization↗
PubMed1995

User fees and drug pricing policies: a study at Harare Central Hospital, Zimbabwe.

In 1991, Zimbabwe introduced cost recovery measures as part of its programme of economic reforms, following a course taken by many developing countries. The system of user fees in public health care, aimed to 'protect and support the vulnerable groups' by exemption or incremental fees based on 4 income brackets. Drugs were charged at a percentage of the recommended retail price in the private sector. This study of 488 outpatients at a referral hospital in Harare examined how the new fee system functioned 6 months after its introduction. Patients were interviewed and their prescription records examined. Mean charges were determined for each fee category and revenue from drug charges was analyzed in relation to purchase cost to determine the gross profit. 31% of patients were exempted from all fees upon proof of monthly earnings of less than Z$150 (Z$5 = US$1). The remainder were classified into three fee-paying categories. The mean purchase cost for drug items was Z$3.89 per outpatient prescription. Outpatients paid a mean drug charge of Z$9.75 after exemption or discount. This was 2.5 times the cost price. The number of drug items obtained differed according to fee status: the fee-exempt category received a mean of 2.9 drug items compared with 1.9 drug items in the fee-paying categories. This difference originated at the point of prescribing. A number of practical problems in fee collection were noted. The drug pricing system generated high profit even after re-distribution to low-income users. This was attributed to economical and rationalized public sector drug procurement. Observation indicated that a proportion of the vulnerable were not effectively protected due to stringent requirements for proof of income. Appraisal of the fee policy indicated the need for more effective cross-subsidy and better administrative procedures; fee revenue should be directed towards improvement in quality of service.

Cost Sharing↗
PubMed1989

Patient perceptions of general practitioner fees.

General practitioner fees were surveyed in a sample of 1033 families with eleven year old children. The median fee paid for a child consultation was $12.00 and for an adult consultation $22.00. The majority of respondents were of the opinion that these fees were too high: over half said this about child fees and over two thirds believed adult fees were too high. Patient estimates of reasonable fees were, on average, $8.00 for a child and $15.00 for an adult. There were clear and consistent dose/response relationships between the fee level charged and the likelihood that the fee would be described as too high. Comparisons of the fees paid by this cohort in 1980 with fees in 1988 indicated that child fees had increased at an average rate of 24% per annum during this period. The implications of these findings for health care delivery are discussed and the possible impact of recent increases in GMS benefits on levels of dissatisfaction with fees are examined.

Adult↗
PubMed2005

User fees in private non-for-profit hospitals in Uganda: a survey and intervention for equity.

BACKGROUND: In developing countries, user fees may represent an important source of revenues for private-non-for-profit hospitals, but they may also affect access, use and equity. METHODS: This survey was conducted in ten hospitals of the Uganda Catholic Medical Bureau to assess differences in user fees policies and to propose changes that would better fit with the social concern explicitly pursued by the Bureau. Through a review of relevant hospital documents and reports, and through interviews with key informants, health workers and users, hospital and non-hospital cost was calculated, as well as overall expenditure and revenues. Lower fees were applied in some pilot hospitals after the survey. RESULTS: The percentage of revenues from user fees varied between 6% and 89% (average 40%). Some hospitals were more successful than others in getting external aid and government subsidies. These hospitals were applying lower fees and flat rates, and were offering free essential services to encourage access, as opposed to the fee-for-service policies implemented in less successful hospitals. The wide variation in user fees among hospitals was not justified by differences in case mix. None of the hospitals had a policy for exemption of the poor; the few users that actually got exempted were not really poor. To pay hospital and non-hospital expenses, about one third of users had to borrow money or sell goods and property. The fee system applied after the survey, based on flat and lower rates, brought about an increase in access and use of hospital services. CONCLUSION: Our results confirm that user fees represent an unfair mechanism of financing for health services because they exclude the poor and the sick. To mitigate this effect, flat rates and lower fees for the most vulnerable users were introduced to replace the fee-for-service system in some hospitals after the survey. The results are encouraging: hospital use, especially for pregnancy, childbirth and childhood illness, increased immediately, with no detrimental effect on overall revenues. A more equitable user fees system is possible.

Journal Article↗
PubMed1994

Medicaid physician payment reform: using the Medicare Fee Schedule for Medicaid payments.

OBJECTIVES: The purpose of this article is to provide estimates of the costs of basing Medicaid physician payment levels on the new resource-based Medicare Fee Schedule. Two possible policy options are considered: setting all Medicaid physician fees at the Medicare Fee Schedule level and setting only office visit fees at the new Medicare levels. METHODS: Data on Medicaid physician fees, use patterns, and the Medicare Fee Schedule are used to develop state-level estimates of expenditure changes under each option. RESULTS: Setting Medicaid rates at the Medicare Fee Schedule level could increase expenditures by $3.2 to $4.1 billion nationally; the other option would result in substantially lower increases in expenditures. Because of the current variations in Medicaid physician fees and in the breadth of eligibility across states, the cost of adopting the Medicare Fee Schedule varies considerably among states. CONCLUSIONS: Adopting the new Medicare Fee Schedule for Medicaid payments, proposed by policy-makers as a way to increase access to appropriate medical care, could double physician expenditures in some states. Adoption of more limited versions of the fee schedule might achieve some access gains at lower costs.

Fee Schedules↗
PubMedDate not supplied

Fees for service. A survey of Indiana and selected jurisdictions nationwide.

It is apparent from the economic realities we face today that in order to maintain substantial programs in the environmental health areas, additional sources of income are needed. The uncertainty of the effects of the Gramm-Rudman legislation, the extremely high cost of insurance, and the need for new environmental health programs indicate that the question is no longer whether it is necessary to establish fees for environmental services but rather what those fees should be. A survey was conducted of all 96 local health departments in the State of Indiana from November 15, 1985 to March 15, 1986. It was found that minimal fees or no fees are charged for environmental services. The rationale for the fees charged was based on factors other than the actual cost of the service performed. Further, a study of environmental fees charged for services in a select national survey in 1982, updated by use of the Consumer Price Index for 1986, indicates that Fees for Service and the rationale for the fees vary widely. The philosophy behind a fee for service program, the potential benefits, the potential problems, the techniques for determining fees for service and the use of public funds are discussed. Appropriate recommendations are made concerning the institution of a Fee for Service Program.

Data Collection↗
PubMedDate not supplied

[Analytic study of the hospital self inspection results with the medical insurance inpatient fee from the viewpoint of the hospital management--based on one university hospital pre-discharge inspection].

The purposes of this study were to evaluate the results of the hospital self inspection with the medical insurance and to offer basic materials to the medical insurance inspection and the education of medical insurance. The study was undertaken with 4,730 cases among the total 13,810 medical insurance in patients from Jan. 1990 to Dec. 1990 at one university hospital in Pusan. The major contents of the inspection were the omission of diagnosis and medical fee, curtailment, application mistake, the rates of inclusion, subtraction and total accumulation. The data were collected using patients charts and bills. The results of the paper analysis were as follows. 1. From the pre-discharge hospital self inspection, major omission were treatment and material fee but medication fee were moderately high and high curtailment was operation fee. 2. Decreasing order of operation fee adjustment were digestive (22.4%) muscular (22%) and neuro system operation (21.4%). Majority of the medication fee adjustments were injection form of medication (95.7%). 50% of the treatment fee adjustments were composed of injection fee (27.9%) and dressing or post-operative dressing fee (22.3%). 74.7% of material costs were composed of oxygen (30.6%), blood and the blood composed materials (44.1%). 3. Pre-discharge inspection showed 6% adjustment rate, 4.3% addition and 2.1% curtailment rate. Most of the adjustment were omission (66.1%). 4. Omission were divided by event omission (92.6%) and application mistake (7.4%). The decreasing order of omission fee were operation (21.84%), treatment (18.71%) diagnosis (18.68%), medication (14.53%) and material costs (10.84%). So operation and treatment part were the major part of the total omission fee (40.55%). 5. The average omission of diagnosis were 1,800 per month.

Fees, Medical↗
PubMed2004

User fees at a public hospital in Cambodia: effects on hospital performance and provider attitudes.

User-fee programs have been introduced at health care facilities in many developing countries. Difficulties have been encountered, however, especially at public hospitals. This report describes the effects of user fees introduced in April 1997 at a public hospital, the National Maternal and Child Health Center (NMCHC) of Cambodia, on patient utilization, revenue and expenditure, quality of hospital services, provider attitudes, low-income patients, and the government, by reviewing hospital data, patient and provider surveys, and provider focus group discussions.Before the introduction of user fees, the revenue from patients was taken directly by individual staff as their private income to compensate their low income. After the introduction of user fees, however, revenue was retained by the hospital, and used to improve the quality of hospital services. Consequently, the patient satisfaction rate for the user-fee system showed 92.7%, and the number of outpatients doubled. The average monthly number of delivery of babies increased significantly from 319 before introduction of the system to 585 in the third year after the user-fee introduction, and the bed occupancy rate also increased from 50.6% to 69.7% during the same period. As patient utilization increased, hospital revenue increased. The generated revenue was used to accelerate quality improvement further, to provide staff with additional fee incentives that compensated their low government salaries, and to expand hospital services. Thus, the revenue obtained user fees created a benign cycle for sustainability at NMCHC. Through this process, the user-fee revenue offered payment exemption to low-income users, supported the government financially through user-fee contributions, and reduced financial support from donors. Although the staff satisfaction rate remained at 41.2% due to low salary compensation in the third year of user-fee implementation, staff's work attitude shifted from salary-oriented to patient-oriented-with more attention to low-income users.

Attitude of Health Personnel↗
PubMed1993

How do Medicare physician fees compare with private payers?

Under the new fee schedule, Medicare physician fees are 76 percent of private fees. Consistent with the intent of payment reform, Medicare physician fees more closely approximate private fees for visits (93 percent) than for surgery (51 percent) and in rural areas as compared with large metropolitan areas. Variation in private fees across the country is considerably greater than it is for Medicare fees. Consequently, Medicare fees are most generous in areas that compare least favorably with the private market because private fees in these areas are well above average. These results shed light on the impact of the fee schedule and on the implications of using Medicare payment methods as part of a broad-based health reform.

Data Interpretation, Statistical↗
PubMed1999

Health for some? The effects of user fees in the Volta Region of Ghana.

This paper reports key findings and conclusions from a 1996 study of user fees and exemptions in the Volta Region of Ghana. A variety of data sources and methods were used, including interviews with patients and managers, community-based focus group discussions, analysis of facility records and analyses of previous household survey data. Official fee levels and exemption categories were established in 1985. While this legislation made provision for drug fees to be 'at cost' and thus to be revised in line with inflation, other official fees have not been adjusted since 1985. In the face of declining real levels of budget allocations and decreased supplies of essential consumables from the Central medical stores, facility managers have established their own pricing and fee collection systems. This has been allowed by the Ministry of Health, but the decentralized nature of fee setting and collection practices has made it very difficult for the Ministry to monitor the effects of fees. The study found that facility managers have been very active in setting and collecting fees and using the revenues to purchase essential inputs. The level of revenues being mobilized accounts for between two-thirds and four-fifths of the non-salary operating budget of government health facilities, and virtually all of the resources for non-salary operating expenses in mission hospitals. Official exemptions are largely non-functional. Less than one in 1000 patient contacts were granted exemption in 1995. With estimates that between 15 and 30% of the population lives in poverty, the failure of exemptions to function means that fees are preventing access for the poor, or are imposing significant financial hardships on this part of the population. Health facilities in the Volta Region have achieved a kind of 'sustainable inequity', with fees enabling service provision to continue, while concurrently preventing part of the population from using these services.

Attitude to Health↗