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Summary Bulletin 10 (August) - DHS-LG Discussion List
FEES FOR PHC SERVICES
The ANC Health plan for South Africa states: -
Free health care will be provided in
the public sector for children under six, pregnant and nursing mothers,
the elderly, the disabled and certain categories of the chronically ill.
Preventive and promotive activities, school health services, antenatal and
delivery services, contraceptive services, nutrition support, curative care
for public health problems and community based care will also be provided free
of charge in the public sector.
In 1994 shortly after the first democratic
elections, the policy for provision of free health services became law – initially for children under 6 years and pregnant women, but this was later
extended to all PHC services.
However it was noted in a remote rural district
that this was not being observed and patients are being charged a fee to attend the clinic. The money being used for such things as: -
- To pay taxi drivers to transport laboratory samples (sputum, blood or urine) to the district hospital for analysis
- To pick up drugs from the district office as there is no transport at the district office
- Soap money for the treatment supporters
- To pay clinic committee members to travel to meetings they are summonsed to by DOH officials
- To pay security personnel at the clinic if they are not formally employed by the service rendering authority
- To pay for minor repairs to the clinic
The question was posed as to whether this was
happening elsewhere in the country.
Although not strictly fee-for-services several similar examples were shared: -
- Community members contributing R5.00 per household to provide lunch for the volunteers who were attending to the gardens on the clinic grounds.
- Community members purchasing additional chairs for patients to sit on.
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A survey of the help-seeking behaviour of people in a rural area found that in addition to small amounts being charged by the clinic committees (collected by the clerks), patients were being charged for the bottles for cough mixture, clinic cards, and certain medicines.
- Elsewhere a small fee has been requested at times in support of a project being set up by the clinic or the community.
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Charges have been made for a new card to encourage the patients to bring their old patient card with them.
- Money has been raised in the community towards building shelters for mobile clinic services
- Collection of money from community members to pay for nurses transport into the community to render services closer to their homes
Donation system of R2.00 per head; later increased to R5.00 per head. The money being used for purchase of variety of items.
Contributions in all schemes are said to be
voluntary. Many of these schemes are seen as a means of extending community
involvement in provision and improvement of health services. The question was
posed; do the communities who pay to such schemes know what they are paying for?
Are there alternative ways of raising funds for community projects than
attaching them to clinic attendances?There were strong opinions expressed that the
provincial or other authority should stop any such schemes and that it is the
responsibility of anyone knowing of these schemes to report it to the
authorities to take action. For example, it was noted that when a local
authority clinic was integrated into the provincial services the fees charged by
the local authority clinic were discontinued.
A number of related issues were raised: -
- Any informal charging needs to be carefully assessed to protect the poor and vulnerable. It is often the really poor who suffer.
- There are wider economic issues to be considered, such as poverty alleviation, and the broader costs that communities have to bear to improve their health status.
- Patients must be informed of their rights to free PHC services. The public sector must ensure that communication in line with Batho Pele principles is adequate to ensure trust between the public sector and community is maintained.
- Charging of informal fees for service is not unique to South Africa. Lessons could be learnt from other countries in dealing with the problem, which may relate to power relationships between the public sector and the community.
- Official contracting of private sector, such as taxis, for transporting specimens, drugs, etc. could be considered as a means of injecting additional resources into the community.
- Payment of a fee-for-service can enhance the community’s feeling of ownership of that service. But, one of the principles of PHC is affordability that must be applied in an equitable way. The question is how much to charge and in what way. Often those who need the services the most can least afford it and those who can afford to pay will do everything possible to avoid paying.
- Whereas it is commendable that the government does provide services free at the point of service, it is equally commendable that communities are prepared to pay towards improving the services. But these contributions should possibly be made in an equitable way per household and not directly at the point of service, as this may create a barrier for the most vulnerable to accessing the services.
Finally it was pointed out by one contributor
that there is no such thing as a free service as this is paid for in time,
transport and often in lack of quality of service provided. So if a small fee
were charged, this could be used to improve the service. Provision could be made
for the destitute to be exempted, thus not violating the constitutional rights
of all people to have access to health care. Careful management of any scheme is
required. The policy of free services may need to be re-evaluated.
Conclusion
It is accepted that in South Africa there is no
fee-for-service for primary level care. This is unlikely to be changed in the
foreseeable future. It is the responsibility of the officials of the health
services to ensure that this right is not violated. At the same time there is a
need to acknowledge that community members may in some circumstances be willing
to contribute financially towards improving service delivery. Furthermore, the
clinic committees’ involvement in it could be seen as successful community
participation, which is a basic tenet of the Primary Health Care Approach.
Summary prepared by: Wendy
Hall [hstwendy@sai.co.za]
Health Systems Trust
October 2003
[The original e-mails, extending from 8th
August to 2nd September 2003, are archived at http://lists.healthlink.org.za/cgi-bin/lyris.pl?enter=dhs-lg
and can be accessed by DHS-LG list members. Registered e-mail address is
required, but password can be ignored.]
The article below was shared with the list
Waivers and exemptions for
health services in developing countries
Ricardo Bitrán, Ursula Giedion (October 2002)
Paper presented at: Protecting the Vulnerable: The Design and
Implementation of Effective Safety Nets - December 2-13, 2002 - World
Bank Institute - Washington, D.C.
Available online as PDF
file [97p.] at: http://www.worldbank.org/wbi/socialsafetynets/courses/dc2002/readings/aldeman.pdf
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