The concept of patients as consumers of health includes the topics of the right to health, cultural relevance, and utilization. However what I find distressing are the ways in which these concepts can be left out of the picture in the top down model of donor and high-income country driven policies, creating inefficient program implementation, which in turn shapes and affects utilization and access to health care.
Although it is important to note that some progress has been made and that overall health care financing has increased globally, particularly with disease specific approaches and largely in the area of HIV/AIDS, there are still issues of inefficiency across socioeconomic statuses and location, predominantly affecting low-income communities. The question then becomes how to better reach individuals and families in these areas. Issues of financing and utilization of services are two areas that can be looked at with more cultural relevance and appropriate systematic mechanisms.
With regards to this, Yates addresses the practice of user fees. What was once thought of as a hopeful solution is now recognized to often have the opposite effect. While this entry will not delineate the specific details of this, I find it important to mention, due to the fact that was once devised to create efficiency, equity, and effectiveness, was soon realized to be inequitable, inefficient and ineffective (Yates, 2009). Of course this would not have been known from the outset, his acknowledgment that “intuitively, we should have known in the context of improvement of health outcomes and reduction of poverty that taking money from poor people when they are sick is not a good idea” (Yates, 2009), implies a grave oversight by the global health community.
While user fees did create some benefits, such as a decrease of unnecessary doctor visits, as well as increased care and funding for some, the allocation of monies that were hoped to cover costs did not occur efficiently, (Yates, 2009). In addition, this ‘solution’ did not address ‘hidden’ costs such as transport or lost wages for time spent out of work, thus creating further burdens on already struggling individuals.
This is particularly evident when the additional attribution of ‘health shocks’ (Leive, 2008) or ‘high catastrophic health expenditures’ (Yates, 2009) are factored into the picture. Leive details how ‘health shocks’ affect not only where treatment is sought out, but also how these unplanned payments actually transpire. As universal health care or insurance is not available in most low-income countries, costs fall into the hands of individuals and families . Coping strategies, as Leive defines, are ways in which individuals and families deal with the financial burdens of these health shocks. While there is some evidence of savings in higher income families, most have reported to utilize the process of selling assets or borrowing from friends and families (Leive, 2008).
This effort of borrowing and selling assets only creates further inequities, greater burdens, and is not considered to be efficient or reliable. It is also likely that these barriers deter people from seeking primary or preventive care due to the possible occurrence of future ailments. While Leive presents data regarding these coping behaviors, the results gathered were found only from those seeking care (Leive, 2008). This leads me to wonder how much larger this gap would be if the number of individuals unable to use these coping mechanisms were accounted for.
The combination these two factors, user fees on top of the additional costs created by health shocks, creates further disparities. Accordingly, in regards to cultural relevance, those creating policies and new programs should look at how utilization would best occur by including country specific cultural needs and values. As the global community continues to engage in discussions on the right to health in the context of patients as consumers, International, National, and community collaboration needs to occur to ensure this translates to healthy communities.
Leive, A., Xu, Ke (2008). “Coping with out-of-pocket health payments: empirical evidence from 15 African countries”. Bulletin of the World Health Organization, 86(11)
Yates, R. (2009). “Universal health care and the removal of user fees”. Lancet; 373:2078-81