The methods of payment indicated by those who were
willing to pay, 21% agreed to enhanced fixed purchee
fees (fixed fee per visit), 32% were ready to pay yearly payments, 27% monthly
payments, and 20% indicated that they would like to pay as per type of care
received according to the severity of disease and drugs prescribed (Fig 1). The
amounts that they have indicated are in shown in Table 3.
Ability
to pay
In 72% of the cases cost was not considered as a
barrier in seeking care and only 19% of the cases considered cost as a partial
barrier, the rest indicated that cost was the major barrier. In case the treatment was not paid from
available cash in the household, the willingness to pay decreased. The delay in
seeking care was also correlated with the decrease in willingness. Further
analysis revealed that 31% of those reporting a barrier had to resort to
financing sources from outside the household. The delay in seeking care also
increased, as the cost became a barrier. Out of those, reporting a delay in
seeking care, 24% cited financial barriers as the reason for delay. The effect
in income groups and socio economic groups was also the same i.e. the low
income and SES groups had a greater problem with costs as compared to the
middle and high income and SES groups table4.
Figure-1: Methods of Payment specified by those willing to
pay
DISCUSSION
Limited data is available on the subject of cost
sharing mechanisms and even less on the willingness to pay for health care in
The 3rd Evaluation Report on
Health For All clearly identifies that Pakistan cannot afford to finance its
health care adequately with respect to its growing population due to allocational and internal inefficiencies.11
The World Bank suggests that
provision of essential curative care services and preventive services will cost
approximately US $12 per capita in the low-income developing countries.12
Calculated at the present foreign exchange parity (Rs
65=US$1) this works out to be Rs. 780 per capita or Rs. 11.154 billion per year just for provision of primary
health care services to the population whereas the per capita expenditure on
health was Rs 160 in 1996-97 by the government.6
The optimal role of government
in the health care sector has been recently redefined in the World Health
Report 2000 as being one of stewardship (“function of a government responsible
for the welfare of the population, and concerned about the trust and legitimacy
with which its activities are viewed by the citizenry”). This shift in role
from provider to steward has yet to take place in the developing world. The
change in the function of the government from a provider of services to a
regulator is still a long way ahead, at least in
Willingness
to Pay
The willingness to pay for normal goods depends on the
tastes or the amount of disposable income available with the consumer, however
in health care the willingness to pay depends primarily on the total wealth of
the consumer and in order to pay for care the consumer may even sell off some
or total fixed assets. If a family spends most of its savings or incurs large
debts in the hope of saving a member's life it is because there is no choice or
alternative available in these families.13 The ability to pay thus
is dependent on the total economic value of the consumer as they may even
mortgage their future for provision of health care. This raises serious
questions about equity and the effect of illness on poor households.
The findings of this study
suggest that the community is willing to pay for the public sector services if
payment will ensure provision of essential curative services (Table-2). The
willingness to pay for public goods (public goods are defined as goods having
indivisible benefits and hence no one can be excluded from consumption for not
paying. e.g. malaria spray ) is less than five percent, if we stretch the
definition to include the responses specifying all types of health care the
percentage still remains below fifteen percent (Table 2). Moreover, there
appears to be a definite pattern to the responses; the willingness to pay for
care is mostly linked to provision of medicines.
The important aspect is that
the willingness to pay is marginally affected by income, place of residence
and/or cost of the treatment incurred. A majority across all strata is willing
to pay, although the responses from the low income and low SES groups exhibit a
slight decrease in the willingness to pay. This is exactly as expected from the
literature.14-19
Ability
to Pay
For
Another important factor to be
remembered in this respect is that GNP Per capita of
The question of the ability to pay requires further
deliberation and research, as to what are the effects of health care payments
on the household budget? What should be the level of exemption from charges?
How will the safety nets for the poor be devised? What are the levels of
affordability and what mechanisms will ensure equity in provision and charging
for care? What are the reliable indicators for assessing the ability to pay for
care? The amounts indicated by the community should be viewed as only evidence
to support the hypothesis that the community is willing to pay and not as the
exact amounts, the community will be able to pay.
The formulation of optimum
service delivery packages, which can be sustained, at the different levels of
care requires careful consideration. The minimum package proposed by the Macro
Economic Commission5 is estimated at $ 34 per person in developing
countries. Sustainability and efficiency in health care delivery should be a
priority but not at the cost of equity in service provision. The need for
government intervention in the health care market as an inherent feature of the
free market economy should be kept in mind. Health care without government
control will invariably lead to market failures: inequitable services
provision, restrict access to care, and preventive health care services will
not be provided.
Despite the limitation that
this study was carried out in one district, the sample population compares
favorably with other national data including the Census22,23,26 with
respect to its demographic and socioeconomic perspectives.
CONCLUSIONS AND RECOMMENDATIONS
The fact that alternative financing mechanisms are
required to ensure provision of essential services is evident even from the
community’s perspective. The high level of willingness to pay for health care
services at the government facilities is in fact an indictment of the current
health care system and an expression of dissatisfaction on the current mode of
health care delivery. The community indicates its willingness to participate in
cost sharing mechanisms for health care but that is linked with the provision
of medicines and availability of personnel. Inferences regarding the methods
that the community is willing to participate in include; a multiple tier fee
structure (variable fee per visit) a fixed fee structure (fixed fees per visit)
and social insurance packages (yearly or monthly payments).
Policy
Implications
The Government's desire to improve the Health Status
of the population is evident from the lofty goals it has set itself in the
field of Health Care but the ground realities are that the requisite resources
are not available with the Public Exchequer. The need for an increase in
expenditure on the social sector specially health is obvious as is the fact
that the condition of the economy does not allow an increase in the current
expenditures. Therefore, to assure provision of essential health care other avenues
need to be explored. The community is willing to participate in different cost
sharing mechanisms but the overriding factor is that a minimal level of service
delivery needs to be guaranteed. The mechanisms for such a guarantee should be
the focus of policy research to ensure sustainability of health services. At
the same time the quest for equity should not be cast aside and the development
of an efficient yet equitable health care delivery system should receive
priority.
The fact that even the low
socio economic group has to resort to the private sector for illness episodes
is an important reminder that the public health care system is failing to
provide the safety net for the poor. Thus, the reason for government
intervention in health market is not being fulfilled. The role of the
government requires careful consideration as to the expectations of the
community and its capacity to accomplish the same given the current economic
scenario that is likely to continue for the near future.
There is an urgent need for
reforms in the health sector with a specific focus on equity and efficiency.
The allocational inefficiencies can be minimized with
the proposed devolution of power plan at the district level but the internal
inefficiencies of the system also need to be improved by streamlining the
organization and structure of health system in
ACKNOWLEDGEMENTS
This study was made possible through a research grant
funded by the World Bank, Health Systems Research program through the Pakistan
Medical Research Council.
REFRENCES
1.
Welch C. Structural
Adjustment Programs and Poverty Reduction Strategies, Foreign Policy in Focus
(www.fpif.org) vol 5 no
2.
World Development
Report, Investing in Health, World Bank, 1993,
3.
Cavanagh J, Welch C, Retallack S. The
IMF Formula: Prescription for Poverty IFG Bulletin, Volume 1, Issue 3,
International Forum on Globalization, 2001,
4.
World Health
Report 2000, Improving Health Systems Performance WHO 2000
5.
Macroeconomics and
Health: Investing in Health for Economic Development. Report of the Commision on Macroeconomics and Health WHO 2001
6.
Ministry of
Health, Government of
7.
Ministry of
Health, Government of Pakistan, National Health Policy, The way forward, 2001
8.
UNICEF, State of
the Worlds Children, 1999
9.
Richard A. Yoeder, Are People Willing and Able to Pay for Health
Services?, Soc Sci Medicine 1989;29(1):24-6.
10. Ministry of Health, Second Evaluation Report, Prime
Minister's Programme for Family Planning and Primary
Health Care, Primary Health Care Cell, 1995-96
11. Primary Health Care Cell, Ministry of Health, Health
For All By the Year 2000: Third Evaluation Report. 1997
12. World Development Report: Investing in Health 1993,
World Bank
13. Kanji N. Charging for drugs in
14. Diop F, Yazbeck A, Bitran R.The impact of
alternative cost recovery schemes on access and equity in Niger, Health Policy
and Planning 10 (3) 1995
15. Wouters A. Improving quality through cost recovery in
16. Shaw RP, Griffin CC. Financing Health Care in Sub
Saharan Africa through user fees and Insurance, World Bank, 1995
17. Gilson L. The lesson of User fee experience in
18. Yoeder RA, Lalani S, Makinen M. Policy options for Financing Health Services in
Pakistan, Volume V, Organizing and Financing Rural Health Services, 1993
19. Latwick JI, Bodart C. User Fees Plus
Quality Equals Improved Access to Health Care: Results of a Field Experiment in
20.
21. Planning Commission, Government of
22. Pakistan Integrated HouseHold
Survey (1995-96) Access and usage of basic health care in
23. Economic Survey of Pakistan 2001-02, Economic Advisors
Wing, Government of Pakistan 2001
24. Pakistan-2010 Programme,
(issued 1997) Ministry of Planning and Development. Government of
25. Human Development Report 1998, United Nations
Development Program, 1998
26. Government of