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NEWS: Roger Dobson Reliance on direct payment for health care in Asia is higher in poorer than in richer countries, new study shows BMJ 2008; 336: 982 [Full text]

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Squaring the Circle?

Steve Thomas   (6 May 2008)

Squaring the Circle? 6 May 2008
Steve Thomas, Lecturer Centre for Global Health, Trinity College Dublin, Dublin 2 Send response to journal: Re: Squaring the Circle?	The result of the study by O'Donnell et al (2008) is barely surprising for those acquainted with international health financing but is cause for great concern both for the achievement of the MDGs and the pursuit of health care for all. The fact is that direct (or out-of-pocket) expenditure from households is the last line of defence. When all else fails, when government is unable or unwilling to organise the financing of health care to those most in need and civic institutions have not been strong enough to fill the gap, then households have to pay. A perusal of WHO (2007) data on international health spending shows that those countries that rely most on out-of-pocket spending are often those low- income countries where the state has collapsed, is collapsing or where there is or has been serious conflict (examples include Burma and Afghanistan). In such circumstances households have no choice but to pay. Yet study after study has highlighted that out-of-pocket expenditure is the least equitable form of health financing (McPake and Normand, 2008). The critical question is what can be done about it. Countries frequently find themselves with minimal financial and other resources for health services. Balancing the books to provide adequate accessible health care seems for many low income country governments like having to square the circle. Yet as many donors push toward the 0.7% target of GNP for their aid disbursement, now would seem an important time for using such a glut of donor funds to bridge the gap. That means using these resources with domestic governments or civil society to create freely accessible health systems. Alternatively, it means using donor funds to pay for health care access for the poorest and most marginalised, and building and strengthening institutions and financing mechanisms that can share risk and meet the needs of the poor. Such research highlights the need for action. McPake B and Normand C (2008)"Health Economics: An International Perspective" 2nd Edition. Routledge. London. O’Donnell O, van Doorslaer E, Rannan-Eliya R P, Somanathan A, Adhikari S R, Akkazieva B, Harbianto D, Garg C C, Hanvoravongchai P, Herrin A N, Huq M N, Ibragimova S, Karan A, Kwon S, Leung G M, Lu J R, Ohkusa Y, Pande B R, Racelis R, Tin K, et al.(2008)"Who pays for health care in Asia?" Journal of Health Economics, Volume 27, Issue 2, Pages 460- 475 WHO (2007) Core Health Indicators. http://www.who.int/whosis/database/core/core_select.cfm Accessed September 2007 Competing interests: None declared