Evidence suggests that user fees exclude the poorest member of society from health care. However, some argue that charging those who can afford to pay can benefit the poorest. In Cambodia, can user fees for public health services provide better wages for staff, and improved services, while encouraging people on low incomes to seek treatment at public hospitals?

The French non-governmental organisation, Enfants & Développment, together with the Centre for Development Studies at the University of Wales, Swansea, undertook a study at a district hospital in Kirivong Operational District to find out what effect charges had on people seeking medical care - particularly those on the lowest incomes.

In Kirivong Operational District, private health care is flourishing with 511 private practitioners operating, of whom 75 are qualified. Around 430 lay people sell drugs over the counter in shops, in markets or from door to door.

Although the district hospital’s services were officially ‘free’ to users, informal payments were made as doctors’ needed to subsidise their low earnings of between US$20 and US$45 per month. Relatively low level fees were introduced for a period of five months to reflect the quality of the services. Fees were then increased when the hospital was able to offer obstetrics and surgery and better quality of care overall.

The study found that:

• When hospital treatment was free, only 20 percent of patients first attended a private doctor or drug seller before visiting the hospital. When fees were introduced this figure rose to 73 percent.
• Private doctors and drug sellers increased their charges as the fees of the district hospital rose. Treatment from a drug seller doubled from US$2.7 to US$5.4, while private treatment by a qualified doctor tripled from US$6 to US$20.
• The total cost per patient rose from US$3.2 when hospital treatment was free to US$19 when hospital fees had to be paid.
• Deaths in the hospital rose from 6.6 per 1,000 patients to 13.6 per 1,000.  People may have delayed seeking treatment due to the costs involved, or they may have received inappropriate treatment from unqualified private providers before admittance to hospital.
• The number of poorest patients using the hospital fell from 16 percent when treatment was free to 5 percent once fees were raised.

Introducing, and then increasing, medical fees created a ‘medical poverty trap’. The poorest members of society delayed seeking care from a qualified practitioner. Their inability to work meant they sank into even greater poverty. Many bought inappropriate drugs from unqualified drug sellers. Some people had to sell land to pay for their treatment.

The following steps need to be urgently implemented:

• The private sector must be regulated to prevent profiteering by drug sellers and qualified practitioners.
• People should be able to turn to the public health sector immediately rather than seek advice from private and unqualified drug sellers.
• If subsidies for the poor are to work effectively, a central fund should reimburse health facilities for treatment provided to the poor (i.e. equity fund).
• In the long term, in order to prevent the ‘medical poverty trap’, a community-based health insurance scheme should be set up. Premiums for the poorest members of society could be paid by the equity fund.

Source(s):
'The impact of the introduction of user fees at a district hospital in Cambodia’, Health Planning and Policy 19(5): 310-321, by B. Jacobs and N. Price, 2004

Funded by: Ministry of Health, Cambodia; Enfants & Développment; Centre for Development Studies, Swansea

id21 Research Highlight: 18 March 2005

Further Information:
Neil Price
Centre for Development Studies
University of Wales Swansea
SA2 8PP
UK

Tel: +44 (0) 1792 295877
Fax: +44 (0) 1792 295682
Contact the contributor: n.l.price@swansea.ac.uk

Centre for Development Studies, University of Wales, Swansea

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