Jorge Matine, speaking to the press about the effects of user fees on the health sector
User fees, charged to users in health units, constitute a barrier to access to health services in Mozambique, according to a study carried out and released by the Citizen Observatory for Health (OCS), on Tuesday in Maputo.
According to the executive director of the OCS, Jorge Matine, citing the study entitled “Socio-economic Effects of User Fees in the Health Sector in Mozambique”, users are extremely harmed by user fees, as they are forced to sacrifice money intended for other expenditures such as food, in order to have access to health care.
Just to get an idea, Matine said, the fees charged range from 50 to 2,000 meticais, depending on the type of service. It should also be taken into account that they vary from hospital to hospital, as there is no legal instrument regulating the charges.
“Let’s imagine a peasant woman who even to buy food for her family has difficulties. How would she manage to fund a simple medical examination? Obviously, she will put two weights in the balance and will certainly sacrifice one, even though both are of extreme importance”, he questioned.
On the other hand, the director explained that user fees are concentrated more in quaternary hospitals, such as central and general hospitals, while in health centers they recognized as user contributions for the provision of services, hence there are cases in which they are paid in kind.
“During the survey interviews, there were reports of patients in maternity wards who had to contribute with candles, water and other types of material needed for labor”, he stressed.
Another justification that does not make sense, for the OCS executive director, lies in the explanation that user fees, in quaternary hospitals, are applied to discourage communities who stop going to a nearby health center, to go to a central hospital for “any” disease.
“They just say that patients should rather seek the nearest services, but we know that there is shortage of material in our health facilities. There are cases where someone always goes to a nearby health unite because suffers from heart failure, but the heath center lacks equipment. Therefore, the patient, for sure, ends up resorting to hospitals that will offer him assistance”, he said.
Matine also said that the user fees demonstrate that the cost is greater than the benefit, which means that the State spends more by paying people to collect user fees, without these serving as a source of income to increase hospital resources.
In view of these findings, the OCS director advocates the elimination of user fees, as it has been concluded that they are not efficient.
In numerical terms, OCS researcher and economist, Denzel dos Santos, who was responsible for presenting the results of the study, argued that the revenue from user fees has contributed, in recent years, an average of only 0.5% in relation to the total expenditure of the health sector. Therefore, the argument that user fees serve to maintain and improve public health services is refutable.
In fact, the risk of these fees causing the exclusion of some families, especially the poorest, from health services is a pertinent hypothesis.
“The evolution of these revenues does not follow some logical trend of revenue collection. Both managers and users showed little knowledge about the process of collecting and using these funds”, Dos Santos said, adding that 56% of users had to sacrifice some basic need – food, electricity, water, transport, among others – to pay for the fees.
“Food proved to be the most sacrificed need”, he noted.
The researcher also said that a large part of the respondents has little knowledge about user fees and the purpose of the funds collected through these legally provided charges.
In addition, the space for corruption and illicit charges exists because there are no price lists posted in health facilities, which allows health professionals have the autonomy to charge higher amounts than those provided for in different services.
“Another important point indicated that, although these fees exist with the primary intention of serving as alternative funding for expenditure in the health sector and for improvements in the quality of public services provided, a large proportion of users and non-users surveyed are dissatisfied with the current quality of services, characterized by a lack of medicines”, he said.
“Due to asymmetry of information on the part of users, acts of corruption may occur unconsciously. In this sense, health expenditure is considered catastrophic for disadvantaged populations”, he stressed.
As recommendations, the researcher highlighted the need to observe the efficiency, effectiveness and relevance of user fees as a source of funding, taking into account the negative effects they represent for the population.
Dos Santos also suggests significantly reducing user fees at the hospital level, where there is more risk of a barrier to entry, catastrophic expenditure. In other words, user fees should be eliminated in Primary Health Care to promote the use of services and reduce billing costs.
Denzel dos Santos, presenting the results of the User Fees survey
Regarding the application of these fees, the head of the quality management and maintenance department at Maputo Central Hospital (HCM), Edmilson Mavie, explained that these were adopted to reduce the use of quaternary hospitals by users who should seek services in health units that provide primary and tertiary level care.
“They also serve as alternative income on account of insufficient resources. Therefore, they do not represent a significant barrier to access”, he said, acknowledging, however, that the fees present a barrier when the most disadvantaged families have to sacrifice some expenditures in order to guarantee their health.
On the other hand, regarding HCM, he assured that the fees are only paid by patients that arrive at the hospital without any guide.
Edmilson Mavie, talking about HCM’s experience in applying user fees
The research, which aimed to analyze the socio-economic effects of user fees in the Mozambican public health sector, covered all the provinces of the country, in a universe of 1,100 users and non-users surveyed in more than 50 health units, including central, general, provincial, district and health center hospitals.
Participants in the Seminar for the Dissemination of Research Results on the “Socioeconomic Effects of User Fees in the Health Sector in Mozambique”