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Sustainable Development

Fee-for-service – a bold measure by the Afghan health ministry

29 Aug, 17 | by BMJ

The Afghan Ministry of Public Health has recently announced a User Fee Regulation under which user fees will be levied for services in secondary and tertiary public health facilities. The details of how much will be charged, for what services, and when the regulation will actually come into effect are yet to be known. What is known at the moment is that primary health care services in Afghanistan will continue to remain free of charge. Moreover, the poor, the disabled, women victims of violence, women undergoing Caesarean section, and students availing services in secondary and tertiary care facilities will be exempt from charges.

Evidence from studies in other low- and middle-income countries  show that introduction of a fee-for-service leads to reduced utilisation of health services both preventive and curative in nature. Improvement in utilisation of curative services has only been observed when there was concomitant quality improvement affected with the introduction of user fees.

The government expects that the revenue generated from the tool for improving quality is the revenue from the fees, which could be used to provide necessary drugs, equip facilities with medical technology, and train staff. Some quality improvement for public sector may include the provision of necessary drugs, equipment, and staff. It must not be forgotten that respectful behaviour towards patients will have a significant impact on the perception of quality among the public and this can be challenging from the public policy perspective.

The implementation of this new regulation will entail several challenges. First, Afghanistan has an estimated 39% poor (~12 million people), and another 36% slightly above the poverty line of $1.25 per day (~10million), meaning that only around 30% of the population may be truly eligible to pay a fee-for-service. Second, identification of the poor will be a major challenge. With some nepotism and corruption the poor could be left outside the system and unreserved. The administration of distributing some kind of ID card for the poor requires a rigorous and transparent process and this is challenging in the current scenario.

Another challenge to user-fee implementation will be the manner in which revenue is managed. A centralised system of channelling the revenue through the finance department and redistributing it to all sectors can be bureaucratic and slow process to affect the quality of services. A decentralised system may be prone to embezzlement of the revenue. One option could be to establish local accountability committees to oversee the proper spending of the newly generated revenue. Local health facility councils could play that role in rural Afghanistan.

With the introduction of the fee-for-service regulation, a small window of opportunity through generating a sustainable revenue could be opened for the Afghan Ministry of Public Health. This is crucial in terms of the country’s current debacle when it is excessively dependent on foreign aid. The Ministry, however, must be prepared for the following:

  1. There will be a sharp decrease in health service utilisation, and thus a poorer health outcome in the coming months after the regulation takes effect, which could continue if the quality does not improve.
  2. The expected revenue from user fees will be limited due to a large proportion of poor in the country.
  3. If the revenue is not managed well, the Ministry could face a flood of criticism for local embezzlement of the new revenue or the disappearance of it in the core budget of the central government, with implications on the legitimacy of the overall government.
  4. As promised, if the quality of services does not improve, the gains in health outcomes in the past decade will be significantly jeopardized and the talk of equity in health services should be thrown out the back window.

Overall, it is a bold and risky measure by the Afghan Ministry of Public Health to strengthen the health system. Yet, as they say, the devil is in the detail: it is the details of implementation that will matter. In the long run, the overall development of the country’s economy is what that will make or break the public health system in Afghanistan.

About the author: Maisam Najafizada is an Assistant Professor of Health Policy at Memorial University of Newfoundland, Canada. He tweets @mayysam 

Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare I have no conflicts of interests to declare.

Is India’s national health policy geared towards achieving the Sustainable Development Goals?

7 Apr, 17 | by BMJ

soumyadeep bhaumikThe adoption of Sustainable Development Goals (SDG’s) in 2015 marked a shift in the global development agenda from the earlier Millennium Development Goals (MDGs) era. SDGs are particularly important for the health sector, since they reaffirm the premise of the Alma Ata declaration that health cannot exist in isolation. SDG’s intrinsically link health with actions in several sectors outside healthcare. As a country which missed several of its MDG targets, the SDGs reflect a new set of challenges for India.

At the 2015 United Nations summit, India’s Prime Minister Narendra Modi said that the “Sustainable development of one-sixth of humanity will be of great consequence to the world and our beautiful planet,” while reiterating his confidence that they will be reached. But how well does India’s latest National Health Policy (NHP 2017) released last month, align with the health related SDG’s?

To its credit, the policy, at the outset, recognises the SDG’s to be of “pivotal importance” and has identified seven priority areas outside the health sector which can have an impact on preventing and promoting health. In the section on urban health policy, the NHP calls for “achieving convergence among the wider determinants of health.” The NHP has identified the following determinants specifically: “air pollution, better solid waste management, water quality, occupational safety, road safety, housing, vector control, and reduction of violence and urban stress.” The policy links this with the government’s focus on “smart cities,” seemingly in tandem with SDG 11. This is commendable. But the omission of other traditional determinants of health that are intrinsically linked to other SDG goals of reducing poverty, hunger, promoting quality education, gender equality, and reducing inequalities (SDG 1,2,4-6,10) is surprising.

In its national programmes on maternal and child health, the policy “seeks to address the social determinants through developmental action in all sectors.” It further says that “research on social determinants of health” will be promoted, combining this with “neglected health issues such as disability and transgender health.” It touches on Panchayati raj institutions “to play an enhanced role at different levels for health governance, including the social determinants of health.” In highlighting the need for “an empowered public health cadre,” the NHP explains they need to “to address social determinants of health effectively, by enforcing regulatory provisions.” And while this is not explicitly mentioned as a determinant in the NHP the insertion of gender based violence in national programs, and the call for increased sensitization of health systems to provide care “free and with dignity in the public and private sector,” is another welcome sign. But in its entirety, these issues that are outside of the healthcare sector are reduced to mere mentions, with very little clarity on policy direction or funding. This merits some concern, considering that the NHP in itself, even outside the realm of SDGs, has outlined equity as a key principle.

In transitioning from MDGs to SDGs, the mention of health was reduced from three goals to only one, seemingly in recognition of the need for concerted policies in tandem with related fields in order for them to have a lasting impact on population health. It would have been refreshing if India’s NHP had categorically specified frameworks for integrated action in non-health related SDG’s such as those focused on poverty, hunger, education, gender equality, clean water, and sanitation. Meaningfully executing any multi-sectoral mechanism means building successful partnerships within diverse ministries and with communities. Given all that has been said about the NHP 2017 repeating many of its targets from previous versions, a succinctly articulated vision for governance and financing for inter-ministerial work to address health would have been refreshing.

Soumyadeep Bhaumik is an associate editor for BMJ Global Health and an analysis advisor for The BMJ. He is a medical doctor working in the field of evidence syntheses and program evaluation in India.  Twitter: @DrSoumyadeepB 

Pritha Chatterjee is an MPH candidate at the Harvard T.H. Chan School of Public Health and an Aga Khan International Development Scholar. She is a health journalist from India, formerly with The Indian Express Ltd.  Twitter: @pritha88

Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no other relevant conflicts of interests to declare.

Disclaimer: Views expressed are those of the authors and are personal in nature.

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