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  • Writer's pictureMuso

Care without Fees Means Care for All

I remember, right after my father passed away, my brother got really sick. He had some type of growth under his shoulder. It grew so big it was like a fist. And there was no money to take him to the hospital. We couldn’t afford it. We had problems eating, moreover going to the hospital, because we knew they would give us a prescription. What’s the point of going, getting a prescription that [costs] over 5000 CFA [approximately $10USD]?” –Nana, resident of Yirimadio, Mali in 2007, before Muso began delivering our Proactive Care model to the area

Medicines that cure the leading causes of maternal and child death are well-proven and inexpensive. And yet half the world’s population lacks access to essential health care. Why don’t people always access the services available to them in the health system? Often times, hidden barriers prevent patients from getting the care they need when they need it. Spatial barriers like the distance to a clinic, and social barriers like gender inequality between husbands and wives prevent families from getting regular care as often as they might need. In the case of the poorest patients, the direct and indirect costs of health care can keep them from ever reaching their Community Health Worker or local clinic. 

By design, health systems charge more than is affordable to poor patients, passing the burden of supporting the financing of the health system onto the sick regardless of their ability to pay. These point-of-care costs, also known as “user fees,” cause patients to rationally delay treatment–sometimes until it’s too late. They may look for less expensive forms of treatment, including using traditional medicine or purchasing medicine from unregulated street vendors. Further, patients are burdened by the indirect costs of transportation, lost days of work, and child care. Combined, the direct and indirect costs of treatment force patients to make impossible decisions between keeping a roof over their family members and food on the table, or treating illness. These trade-offs consequently deter many from seeking care through the formal health care system, or force patients to accept catastrophic health expenditures which drive them further into poverty.

This matters as we work to end preventable child deaths around the world. When a child shows symptoms of malaria or diarrhea, they are more likely to survive if they receive care immediately, rather than delay treatment because of barriers like cost. By conservative estimate, if user fees were never implemented in twenty African countries, we could have prevented the deaths of three million children in the last twenty years.

This matters as we work to prevent the spread of communicable diseases. Patients that don’t make it to their CHW or clinic due to cost burden are more likely to have cases that go untreated and increase the likelihood of disease transmission. 

This matters as we work to achieve the United Nations’ Sustainable Development Goal 3 of good health and well-being for all by 2030. Governments and multilateral bodies can work to increase the availability and quality of health care, but if systems are not designed to be accessible to poor patients, we will have failed in both our global commitment to universal health coverage and in the delivery of justice. 

In contrast to traditional delivery models, where patients bear the costs of reaching the health care system, Muso’s Community Health Workers deliver care directly to the patient’s doorstep, treating many illnesses in the home, and referring to clinics when appropriate. We eliminate user fees for all services and prescriptions across our spectrum of care. In the regions where we have tested this model in partnership with the Malian government, we have seen sustained reductions in child mortality, ultimately reaching a rate of child death on par with the United States. This evidence backed the recent commitment by the Malian government to eliminate all user fees for children under five, pregnant women, and elders, and provide contraceptives nationally at no cost. The government also committed to making all care free at point-of-care at the Community Health Worker level.

Announcements like the one made by Mali’s Ministry of Health have become more frequent among African governments in recent years. A 2018 study by the World Bank reported that 33 African countries have either reduced or completely eliminated user fees. This trend signals a rejection of the health care financing policies falling under the umbrella of the Bamako Initiative, designed by UNICEF and signed by African ministers of health in 1987 in Mali’s capital. The Bamako Initiative was designed to increase the sustainability and availability of drugs and health care services in sub-Saharan African countries by making the patient pay. By 1999, thirty-five countries had implemented its basic tenets. Though the Bamako Initiative called for “the poorest to receive access to primary health care,” the financing mechanisms it deploys–user fees–necessarily preclude the poor from accessing treatment. An expert notes, “Despite laudable intentions, it is clear the Bamako Initiative failed miserably–especially in its primary objective of helping poor families access health care…. Faced with underfunded services, high user fees, and non-functioning exemption mechanisms, poor families effectively stopped using public health facilities.” An extensive body of evidence, amassed through 30 years of research, has established: charging poor patients out-of-pocket user fees does not recover significant costs, provides only an illusion of sustainability, decreases access to care, and ultimately kills children. In light of this evidence and a careful comparative study of health care financing mechanisms, we have concluded that user fees are ineffective at achieving their goals, dangerous to patients, and counter to our objectives.

Fortunately, there are justice-oriented, realistic answers to the question the Bamako Initiative set out to solve thirty years ago: how do we pay for universal health coverage? As countries, including Mali, reconsider the user fee model, they can explore financing mechanisms such as tax-based financing, social health insurance, the reallocation of current resources, additional outside investments for health, and the introduction of new efficiencies in per capita health care costs due to cost savings in a healthier population. As Muso provides technical assistance to governments on financing a public-sector universal health coverage system, we start from the investment our patients deserve. As

Frameworks for policy setting that rely on today’s evidence or cost as ‘fair’, ‘realistic’, or ‘sustainable’, without questioning the size of the resource envelope available to finance care lay the groundwork for continued substandard health in impoverished nations. Unless we as a global community believe that the current vision of universal health coverage is only applicable to select populations wealthy enough to afford it, this framework is insufficient and replicates the selective primary health care nihilism of the past. — Joia Mukherjee, Muso Board member and Partners in Health's Chief Medical Officer (co-wrote earlier this year)

As countries move to adopt new financing policies with the support of investments from bilateral and multilateral partners, we must deliver solutions that will solve the foundational questions the Bamako Initiative failed to: the effect policies have on the poorest populations, and the commitments that will be required of us to deliver care to every patient, when they need it. They deserve nothing less.


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