The contribution of user fees to the functioning of health facilities in the National Health System (SNS) is very low, at around 0.6% of total public spending, according to unveiled public by the Citizen Observatory for Health (OCS) at the Conference on Access to Health in Mozambique.

The event, which took place last week in Maputo, aimed to reflect on financing in the health sector, its impact on access to care and the guarantee of the right to health in Mozambique.

At the conference – organized by the Alliance for Health, a consortium made up of the Citizen Observatory for Health (OCS), MedicusMundi and NAMATI Mozambique – the OCS researcher, Rogério Simango, who presented the results of the study, said that user fees are not synonymous with an improvement in the provision of health services in the health facilities where they are applied.

The conference – which was supported by Potenciar – brought together, in addition to civil society organizations working in the health sector, representatives from the Ministry of Health, the Ministry of Economy and Finance, among others.

The user fees, said the researcher, are not considered relevant, as they do not generate significant value in the health sector budget.

The study, which discusses the socio-economic effects of the mechanisms for generating funds to finance the health sector, also states that there are discrepancies between the planning and execution of user fees, as well as a lack of information on how they are managed.

“There is no single complete information circuit on user fees, which includes collection data in all health units, declarations at the Tax Authority, consignment by the Ministry of Finance (MEF) and their use as a source of funds in the health unit”, Simango said.

The researcher – citing the results of the study carried out in various hospitals in the country, spatially central – there was no relevance in implementing policies on user fees, taking into account social inequalities.

“Another finding has to do with informal payments on these prescriptions, since the majority of payments (72 per cent) are made at the front desk and not at the counter, which contributes to the lack of improvement in service provision”, the research points out.

Citizens Sacrifice Food Money to Pay User Fees

In order to meet user fees, citizens are forced to sacrifice money intended for food. In other words, the study concluded that a total of 56 per cent of users have to sacrifice their consumption of essential goods and services in order to pay user fees, mainly by reducing the funds earmarked for buying food (i.e. a total of 36 per cent of those surveyed).

Simango said that there was still no widespread publicity about the amounts charged as part of user fees, or even about the fact that user fees are an integrated policy in the Ministry of Health’s Strategy for the Prevention of Illegal Charges (MISAU) 2017-23.

“Furthermore, the study found that there is a low level of understanding of user fees, i.e. users have difficulty understanding what the fees. Uncertainty, payment is one of the causes of non-utilization of services”, said Simango.

“Fees are not standardized between hospitals. The autonomy of hospitals leads to an increase in fees for multiple procedures and big differences between them”, he added.

In another development, citing Presidential Decree 34/2015, Simango said that it requires the Ministry of Health, in coordination with the Ministry of Economy and Finance, to define the prices charged for the provision of health services.

The decree aims to guarantee transparency, fairness, equality and public integrity, as well as setting prices in places accessible to users. However, according to the study carried out by the Citizen Observatory for Health, only 14.2 per cent of those questioned said that price lists were displayed in the health facilities they attended.

In this context, the survey points to the need for the Ministry of Health to compile and share information on user fees in the country, including informal payments. The study also suggests the need to analyze the efficiency and relevance of user fees as a source of funding for the health sector, taking into account the negative effects they have on the population. On the other hand, there is a need to reduce user fees because they represent a barrier to the use of health services. Likewise, the government should study the elimination of user fees in Primary Health Care, in order to promote the use of services and reduce collection costs.

Challenges persist in health centres

Also at the conference, NAMATI Mozambique presented data from the National Campaign on Respect and Privacy in the country’s Health Units.

According to the organization’s researcher, Eduardo Malo, the survey describes the challenges faced by users of health services in health facilities, with emphasis on hospital infrastructure, hygiene conditions in bathrooms, and the lack of medicines in hospital pharmacies.

 “We still have huge challenges in the health sector, especially in terms of service provision. Although we have made progress in the strategic plan from 2014 to 2019, we realize that only 10% is directed towards the health sector, which is insufficient when you take into account the needs that this sector faces,” said Malo.

On the other hand, MedicusMundi, in partnership with Spain’s GREDS University and the National Health Institute (INS), presented research into public sector funding and its impact. The presentation was led by professor and researcher Ellis Bordes, via the Zoom platform.

For his part, professor and researcher Marcelo Oacha shared Argentina’s experience, stating that the government manages to recover all the resources that the public sector spends on citizens who subscribe to public health services, even if they have health insurance.

“It’s an experience that can be put to good use by the Ministry of Health, to increase the gains in financing this sector in the country”, said Oacha.

Finally, the coordinator of the Alliance for Health, Violeta Bila, argued that the event was held with the aim of reflecting on the financing of the health sector, taking into account its sustainable development. The coordinator said that health services must be offered in an uninterrupted way, from resources to infrastructure, so that the conditions in health services can effectively cover all Mozambican citizens.

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