Rebecca K. Nichols – Patients as Consumers (Blog #2)
Thinking about patients as economic consumers, as we do in the United States, carries certain assumptions about access and agency that translate oddly, at best, for most people in extremely resource-poor countries. (Actually, it probably doesn’t translate well to poor communities in the US, for that matter.) The vast majority of people in the developing world have absolutely no voice in what kind of healthcare is available to them. Coverage is extremely thin, particularly in rural areas, and quality of providers and facilities dangerously variable.
In their study on “Bypassing primary care facilities for childbirth: a population-based study in rural Tanzania,” (Health Policy and Planning, 2009), Kruk et al conclude from their own and others’ research that the high rate of bypassing more convenient government health centers (or birthing at home) by women about to give birth reflects that rural health facilities in Tanzania are indeed poor in quality, and that women are well-aware of their deficits. These laboring “bypassers” certainly are exercising agency, voting with their feet to reach a more distant facility in the hope of a safer birth, but most often with increased financial and potential health costs as a result.
So, increasing infrastructure quality, along with coverage, across primary health facilities is an obvious long-term goal in efforts to improve healthcare for residents of the poorest countries, and will hopefully get due emphasis in fora on the health MDGs. In the meantime, though, developing country healthcare consumers face an additional heavy barrier to care in the form of formal and informal healthcare fees.
Yates observes in “Universal health care and the removal of user fees” (Lancet, Vol 373, June 2009), that user fees are discredited even in the eyes of the very donors who had encouraged them in the first place – sensible, given that studies show they reduce usage, particularly among poor people, and don’t raise substantial funds – but that the remaining cost barriers, like informal fees and travel costs, are high. As Diop et al wryly note in their study of pilot health cost recovery schemes (“The Impact of Alternative Cost Recovery Schemes on Access and Equity in Niger,” Health Policy and Planning, 1995), “… free care in most developing countries in general, and in sub-Saharan Africa in particular, is illusory.”
So, how do health consumers needing high-quality essential care – like those almost-mothers in Tanzania – afford it without running the risk of financial ruin? One answer is Cash Transfer (CT) programs, described in Just Give Money to the Poor, by Hanlon et al (Kumarian Press, 2010). CT programs dispense small amounts of money on a predictable basis, sometimes with socially-oriented strings (like immunizations or keeping kids in school). Careful tracking has shown their effectiveness in helping people combat poverty’s worst effects, mainly because the reliable nature of the transfers allows for planning and saving – for agency. It turns out that most poor consumers are rational in their use of money, once they have it. A little cash on hand, those women in Tanzania would leave inadequate facilities in the dust.