Commentary: should mother and child health services in developing countries be free?

BMJ 1997; 314 doi: (Published 29 March 1997) Cite this as: BMJ 1997;314:941
  1. Anthony Costello, reader in international child healtha
  1. a Institute of Child Health London WC1N 1EH


    Charging users for primary health care services in developing countries has been an intensely controversial issue over the past decade. The World Bank and donor governments have promoted “community financing” through user charges as part of health sector reform.1 The arguments seem compelling. Potentially, user charges give a perceived value to services and deter frivolous demand; provide incentives for staff; remove the hidden, unofficial charges levied by unscrupulous health workers or parallel markets; and ultimately increase use by improving service quality. In the poorest countries, where government spending on health may be below £2 per head, there would seem to be no alternative.

    But many health professionals working in the field doubt these claims. Demand for services by the poor and the vulnerable sections of the population–such as mothers and children–is not “price inelastic” (that is, the demand is sensitive to small increases in price). Appreciable declines in the use of services for antenatal care, maternity care, child health, and sexually transmitted disease have been reported after the introduction of user charges.2 Declines in demand are greatest among the most socioeconomically deprived sectors.3 Concerns have been expressed about the extent to which revenue from user charges can finance quality improvements alone (studies show that 2-32% of operating costs can be recovered4), the burden of administrative costs, and the potential for perverse incentives–for example, encouraging over-prescribing, over-investigation, or corruption. Exemption schemes or differential charges to ensure that the poor sections of the population are not denied access to basic health services are difficult to implement.5

    Interestingly, South Africa has bucked the international trend. With democracy under Nelson Mandela, the policy change has been in a different direction–that is, from user charges to free services. Wilkinson and colleagues have documented the impact of a new policy on free care for mothers and children in a rural district and shown a substantial increase in the use of treatment services by children and of antenatal care for mothers. Users have generally welcomed the policy change. More detailed study is needed to evaluate the impact on health outcomes such as maternal and child mortality or serious morbidity rates. These indicators might have improved if the increased attendance reflects earlier presentation of potentially serious illness. The picture is not, however, straightforward. Staff have been under stress from the greater workload and feel that many attendances for self limiting diseases are frivolous. The authors conclude pessimistically that “the demand for treatment services is probably almost limitless.” This need not necessarily be so if primary maternal and child health services only are considered. In Britain universal free care for mothers and children was introduced in 1948 when health and wealth indicators were not dissimilar from those in modern South Africa. In Britain the demand at the primary level was contained as the health of the nation improved and family size declined. Few would argue for the abolition of this free care policy today.

    Wilkinson et al have certainly raised important questions for South African managers and professionals. The immediate options might be to improve triage to educate users about the proper use of primary care and to develop a debate within communities about realistic expectations from services.

    But the current economic situation in Britain (gross national product per head £12 227) and indeed South Africa (£2026) is a far cry from the 59 low income countries (mean gross national product per head <£500) such as Rwanda (£53), Mozambique (£60), and Ethiopia (£67). For these nations user charge schemes, however inequitable, will remain the only option to ensure additional investment in primary health care, unless recurrent costs are subsidised in the medium term by international aid or concessionary loans.


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