Introduction

The Citizen Observatory for Health (OCS), in order to find out the consequences of special rates (also known as user fees) practiced in some public hospitals in Mozambique, observed that they constitute a barrier for people – especially for those who live with less of a dollar per day.

The user fees, from the point of view of OCS, constitute harms the citizen’s pocket, in a country where most of the population lives on less than a dollar a day.

The research, which is in its first phase, began in February of the current year, contemplating hospitals in the cities of Maputo, Beira, Nampula and Quelimane. It points out that, in the hospital centers of these cities, the special fees diverge, meaning that there is a stipulation of prices for access to health care. Everything indicates that the institutions in allusion simply display the fees without following a logic method.

The “privatization” has been going on for at least five years in front of everyone’s eyes, and citizens with a low monthly income are being excluded in the access to health.

The rates start at 200 meticais, reaching a little more than 1,500 meticais, harming the Mozambican population that lives with less than 1 dollar a day.

“This is an injustice. It seems that the most important people are those with much money. We, who don’t have conditions, are forgotten and abandoned. We don’t have the same rights. We arrive early, but others are given preference”, complains a user heard by the OCS.

In several hospital units, the OCS has witnessed cases in which patients who are able to meet the demand for special fees are privileged. This situation represents a direct privatization of the system, excluding several users of public hospital.

Different Branches on Special Fees

Among academics and scholars, the application of user fees in Mozambique has raised debates and different wings of thought. There are two branches, the first of which argues that user fees are necessary because they constitute a mechanism to obtain funds to be used internally within the hospital. The second branch, on the other hand, argues that fees are harmful because they jeopardize the underprivileged.
The controversy dates back to the 1980s, and the World Bank has been in favor of user fees, considering them a fiscal space where funds can be obtained within the health system.
In Mozambique, a country characterized by economic and financial shortcomings and other social factors, the fees have been a barrier to accessing health services. On the other hand, the fees clearly violate the constitutional right to health.

Profile Hospital

The organization of hospitals in Mozambique is subdivided into four levels, namely: primary, secondary, tertiary and quaternary level.

The primary level includes rural and urban health centers; secondary level covers rural and district hospitals; tertiary level covers provincial hospitals and, finally, the quaternary level covers central or specialized hospitals.

In this paper, however, we debate about secondary level (general) and quaternary level (central) hospitals, as well as provincial hospitals.

General hospitals have the function of providing secondary health care, as well as being the first level for patients who cannot find an answer in the health centers.

On the other hand, central hospitals are essential for patients who cannot find solutions at the provincial, district, rural and general hospitals, as well as for patients coming from District Hospitals and Health Centers, which are located nearby. This work covers quaternary hospitals, as well as secondary level hospitals, highlighting only general hospitals, in a universe consisting of rural and district hospital.

CENTRAL HOSPITAL OF MAPUTO

One of the oldest fees at Maputo Central Hospital (HCM) dates back to 2016, in the oncology sector. Since then, this fee has not been changed, although there is an increase in other sectors. The number of charges for the special fees range from between 200 meticais, to 1,500 meticais, for consultations only. These fees are far above what is charged in normal services for consultations, one metical. The criteria for setting these fees have never been answered.

Although these fees were posted in 2016, they have been aggravated.
As an example, in 2019, a notice was posted announcing that a total of 5000 meticais would be added, for surgical intervention, to the rate already established.
These fees constitute a barrier in a country where people live under a dollar and with the minimum wage, evaluated at around 4 thousand meticais.  Note that for each visit or consultation, for example, in the case of dermatology, the user must pay 900 meticais for the consultation. This value, associated with the cost of medicines, is unsustainable for the common citizen.
A young woman heard by the OCS, after visiting the dermatologist, speaking on the condition of anonymity, showed her prescription valued at more than 7 thousand meticais. In total, her trip to the HCM, to diagnose and solve the problem, was budgeted at approximately ten thousand meticais.
The doctor said that I should go there three times and each time I had to pay 900 meticais. In my neighborhood hospital, there is no provision of this service and I was not transferred. Arriving at the Central Hospital, I faced with this situation.”
Another young woman said, after the consultation, that “I don’t intend to return anymore, because I can’t afford it. I live with my parents. My mother is a domestic worker and earns 3,000 meticais and my father is unemployed, he was an employee of a garbage collection company in Maputo City. So, I am forced to live with this skin problem.”
3.2. Hospital General José Macamo
At José Macamo General Hospital, the OCS could only identify the provision of special services in a normal consultation in the stomatology sector, valued at 400 meticais, and the urgent consultation is valued at 700 meticais. 
MAVALANE GENERAL HOSPITAL
In 2018, Mavalane General Hospital posted an announcement with a rate of prices to be effective on September 1 of the same year.

Lúrio University is a higher education institution that houses several faculties, with emphasis on Health faculty. Located in Marrere neighborhood, administrative post of Natikiri, Nampula City.

In order to respond to issues related to the health of the needy populations and without conditions to make specialized consultations, the University created a health center with the intention of minimizing the problem of special health services within the neighborhood.

The assistance to patients is carried out by final-year students of the health faculty, with the help of their professors. In the process, the center also serves as a place for students to put their knowledge into practice.

The consultations, in this health center, according to the price table of the Optometry Clinic, are divided into two categories, namely: Public and Private Consultation. Thus, the prices of a public or normal consultation range from twenty-five (25.00) to fifty meticais (50.00). In the private or specialized consultation, however, prices vary from one hundred (100,00) to five hundred meticais (500,00).  

Nampula Military Hospital

The Military Hospital of Nampula is a public institution located in the neighborhood of Muhivir. Data collected in the field indicate that this hospital has a considerable number of services, since it is one of the largest after the Central Hospital of Nampula and Marrere. The services provided in this center are public and specialized. The price list for specialized services, however, does not appear on the public spaces of the same institution, as in the Central Hospital of Nampula, Marrere and the Health Center of Lúrio University. However, it was found that prices range from two hundred meticais to five hundred meticais.

Nampula Central Hospital

The Central Hospital of Nampula is one of the largest in the province, located in the cement zone. The service at this hospital is both general public and specialized.

The public consultation has to do with the normal consultations made for patients without conditions to resort to private clinics, where the service is restricted or personalized, all within the same hospital. The hospital assists people coming from other provinces and Cabo Delgado. Some patients resort to this hospital for hospitalization. In this hospital, we do not have the price table posted in public spaces.

The Observatory requested the price table for the work done in the hospital, and simply received an oral response, which indicated that the prices of consultations within the clinic vary from one thousand five hundred (1500.00) to three thousand meticais (3000.00). The only table available did not refer to the price table, but to food consumed by the users, varying from five (05,00) to two thousand meticais (2000,00), according to the table below:

Marrere General Hospital

Marrere General Hospital is located in the neighborhood of the same name, in the administrative post of Natikiri. This hospital has inpatient capacity as well as providing special services. The table of services is notable in some sectors, such as the stomatology sector. In turn, it varies from one hundred and fifty (150,00) to two thousand and five hundred meticais (2500,00). These values, according to a source heard by our team, are exorbitant.

Quelimane Central Hospital

The basic health services in public hospitals, in Zambezia province, such as emergency consultations and others, have led to debates due to the rise in prices charged, which have overly affected low-income families.

It is known that most of the Mozambican population, especially in Zambezia, lives with less than 1 dollar a day and, the high fees paid in public health units, such as the Central Hospital of Quelimane (HCQ), General Hospital (HGQ), Coalane Health Center, 24 de Julho Health Center and others in this part of the country, puts into question the right to access to medical-medicine assistance for citizens, with focus on the poorest people. In this province, according to research, Quelimane Central Hospital (HCQ), Coalane Health Center, 24 de Julho Health Center and others, have high prices, which suffocate the pockets of users, according to images in our possession.

In conversation with some users, we found that the fees paid for special services in public hospitals are unsustainable, forcing public hospitals to reduce the fees, considering that most of the population is of low income.

For example, in these public hospitals, services for the first consultation for gestational monitoring cost up to 1,500 meticais; consultations with gynecologists up to 1,000 meticais; physiotherapy over 2,000 meticais; among others. These prices violate basic human rights, as well as making access to health services impossible. The only hospital in Zambezia province that provides special consultations is the Central Hospital of Quelimane. The price rate, however, is not displayed in any of these hospitals’ public space.

Coalane Health Center

In the Coalane Health Center, in an informal conversation with some doctors, we learned that there are no special consultations. They only resort to normal consultations that cost 1 metical.

24 de Julho Health Center

So, we went to the 24 de Julho Health Center and also learned that it offers special consultations in Dermatology, Orthopedics, Pediatrics, Oncology. The only normal consultation available is Stomatology, which also costs 1 metical.

Quelimane Central Hospital

Like the Health Center of Coalane and of 24 de Julho, the General Hospital also does not provide special consultations. All special services operating at the Central Hospital have been transferred to another hospital in the province.

After visiting the three health facilities, we went to the largest hospital center in the province, the rates for special consultations were not posted in the hospital window. The same prices are unsustainable for citizens’ pockets, according to the table below:

Price list for each consultation at HCQ

These fees charged at this public hospital do not include access to medical assistance, as well as access to medication. Because it is the only hospital in the province with these services, according to some users, it causes managers to raise fees, compromising the right to medical care for the population, since the services are unsustainable.
A careful review of the National Health System legislation, in its article 2, determines that every citizen has the right to free medical and medication assistance when inpatient. In article 6, free outpatient treatment is established for medicines considered basic.
In addition to the National Health System legislation, the Universal Declaration of Human Rights (UDHR) determines that every person has the right to a healthy and stable life.
“Health is a right for all, everyone has the right to care and access to basic health services and medicines considered essential,” states World Health Organization (WHO).
The Right to Health corresponds to a set of norms of private and public rights, with the main objective of promoting human health, whether from the perspective of individual or community care.
The National Health System works through a mechanism of gratuity, with a symbolic fee for hospitalization and outpatient treatment. However, poverty levels and the lack of stable sources of income end up constituting a barrier for populations to access health services, as the fees are added to other costs, such as medication, consultations, transportation, and food.

Beira Central Hospital

In Sofala province, we visited Beira City, where only the Central Hospital has special consultations. The prices below involve only consultations, not including other services. In this health unit we faced difficulties in accessing more information.

Main Findings

Throughout this research, the Citizen Observatory for Health found out that the special fees charged at public hospitals constitute a barrier to access to health care. It means that the disadvantaged populations, especially those living on less than a dollar a day, lack the funds to meet the demands of health centers. In addition to the barrier posed by the fees, we note the following points:

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