Impact on child mortality of removing user fees: simulation modelBMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7519.747 (Published 29 September 2005) Cite this as: BMJ 2005;331:747
All rapid responses
The ethics of the influence of the International Monetary Fund (IMF)
and World Bank (among other global organizations) have been raised before,
but I believe we should look at this is a different light. The
intervention of global organizations in the public health systems of
African countries, such as the imposition of user fees for primary care
which are now advocated to be dropped(1,2), is a form of research
involving humans and should be subject to the Declaration of Helsinki(3)
and Good Clinical Practice Guidelines(4).
In structural reforms, global organizations (the investigators) work
to convince the governments of countries (legal representatives of the
study subjects) to take part in health financing reforms (or policy
experiments, the new “medical” procedure). Since the health consequences
of the interventions are largely unknown and the outcomes are used as a
basis of an evidence-base, these ‘policy interventions’ are a form of
experimentation (medical research) and should be subject to the same
scrutiny as other studies – but we find that they fall far short.
The Declaration of Helsinki is infringed in a number of ways: from
the main consideration being related to financial outcomes rather than the
well-being of the human subjects (reduced government budget deficit is a
poor surrogate marker of the real health outcomes), to the conflicts of
interest arising from the dependency relationship between the global
institutions and the national governments such that “research is combined
with care” and the volunteers give “consent under duress” in the light of
the financial inducements to participate. In addition, where governments
are without suitable expertise, it could be argued that these volunteers
“cannot give or refuse consent for themselves”.
It is difficult to comment on the extent to which ethical
considerations are taken into account. However, there is little input from
the subjects themselves given the way that the reforms are commonly
imposed on the populace by government under pressure from the IMF (one
might argue that there should be a national referendum on the issue of
whether to implement health care reforms when there is no evidence upon
which to base reasonable expectations of outcomes). This together with the
lack of complete public disclosure of the potential benefits AND risks
impact on the rights of the subjects of medical research and their ability
to truly consent.
Other failings are evident in the lack of an independent ethical
review (the governments are not independent since they represent the study
subjects and face strong incentives to participate) and there is no
equivalent of an independent data monitoring and safety committee to
determine whether negative consequences are outweighing perceived benefits
so as to bring an earlier end to adverse interventions. Furthermore, there
should be a compensation mechanism for subjects who find themselves worse
off as a result of their participation in the experiment, yet the
organizations which recommend or even impose the reforms take no financial
or moral liability for any unfavorable outcomes, rather leaving it to the
governments to take care of the consequences.
Some may find the argument apparently frivolous, but global funding
institutions need to be made more accountable for their actions in
‘experimenting’ with national health systems. This analogy extends to
other global organizations whose decisions or actions have ramifications
for global health, for example the World Trade Organization and the
influence of the TRIPS Agreement on prices of and access to medicines.
Greater transparency in the deliberations of such organizations and
ethical review of agreements between international financiers and local
governments by independent health bodies e.g. Médecins Sans Frontières
would be a small first step until more comprehensive guidelines can be
developed to assist both ‘researcher’ and ‘volunteer’. Global
organizations must be seen to act within international accords and the
individual’s right to the “highest attainable standard of physical and
mental health” (International Covenant on Economic, Social and Cultural
Rights 1966) must be protected by putting real measures of health before
the surrogate marker of economic outcomes.
1. James C et al. Impact on child mortality of removing user fees:
simulation model. BMJ 2005;331:747-749
2. Gilson L, McIntyre D. Removing user fees for primary care in Africa:
the need for careful action BMJ 2005 331: 762-765.
3. World Medical Association. Declaration of Helsinki. 52nd WMA General
Assembly, Edinburgh, 2000.
4. Council for International Organizations of Medical Sciences.
International ethical guidelines for biomedical research involving human
subjects. Geneva: CIOMS, 2002.
Competing interests: No competing interests
Premarriage Checkup Center In Nasser Institute Hospital “PCC-NIH” in
Cairo – Egypt, is the first center for “Premarital Tests” PMTs in the
Middle East, opened its door in mid-July-2001.
As a developing country the people need low cost PMTs for couples
that are already loaded with the costs of marriage itself. We used the
family history (FH) collecting data tool and pedigree to specify the
single or most specific two genetic tests strictly needed to confirm the
carrier state or the risk in the new families that pass PMTs, with
preference for simple laboratory tests as hemoglobin electrophoresis, G6PD
or CK enzyme assay, lipid or coagulation profile and blood sugar. We use
Karyotyping or Aminogram if there is an offspring FH of mental
retardation. Advanced Cytogenetic, molecular or enzymatic genetic tests
are used in a rational manner depending on clear need appear in FH. We
give advice for couples, for example: to be introduced in “Diabetes
Prevention program” including their coming children in case of risk of
diabetes and to do prenatal tests in case of risk of an inherited disease
in the new family.
Our medical sheet has two categories. The first category is FH of
chronic disease in adults of the family, especially Diabetes Mellitus,
Hypertension, Ischemic Heart Disease and Malignancy. The second category
is Offspring FH for inherited or congenital diseases in children of the
family, especially Mental Retardation, Hemoglobinopathy, Congenital
anomaly and other major diseases.
As I have managed the center for 4 years, I suppose that general
practitioner doctors in “Primary Care Units” can do ninety percent of the
job, they can collect FH for couples going to be married, do a pedigree
and apply the Mendel’s law then elect the couples that need advanced
premarital counseling in a center like PCC-NIH where experts are available
for help. This will be commercial for wide based PMTs in developing
countries as we suggest here in Egypt.
Competing interests: No competing interests
You have in this issue managed to address some key issues affecting the
Third World health system and disease burden and I wouldlike to commend
you for this effort.
May I kindly be allowed to respond to the two articles, 'Impact on
child mortality of removing user fees: Simulation model' and 'Removing
user fees for primary case in Africa: the need for careful action' in one
article? The reason is simply because they discuss the same issues, albeit
a little differently.
I do not have much to discuss on the first of these as I entirely
agree with the issues raised. The key ones being the need to abolish or
remove user fees and secondly on the need to ensure that viable alterative
funding mechanisms are available when user fees are removed. One could go
further about specifying such alternative financing mechanisms and raise
the integrated approach of formal sector and informal sector social
insurance schemes; increased national budget allocations and priority
setting to the health sector; developing social capital at the community
level to develop health and other social services; regulated private
health insurance; earmaking taxes on 'negative consumption' - e.g.
alcohol,tobacco and tobacco related goods, motor vehicles etc.
Di and Lucy however appear to raise somewhat different perspectives
on what is evidently, a straight forward policy and technical issue
inherently responsible for prolonging ill-health, aggravating mortality
and accentuating poverty and deprivation. There has been a positive
correlation between poor economic performance ( and increased poverty
incidence) and application of user fess in Africa and Sub-Sahara region.
The impact on household income and povery of user fees has been
documented. However, the arguments about resource mobilisation potential
of user fees have been continuously made. In the circumstances where
communities are too poor to pay the minimum fee realistically possible,
options requiring community labour to provide support to the health care
providers have been proposed and implemented - thus having no monetary
gain to the system. The recommendations discussed in Di and Lucy's
articles on the need for caution appear to miss the point. How long would
we expect trade imbalances to be redressed prior to preserving life and
avoiding illnesses. That, trade imbalances should change is of course
necessary. But that should not be linked to issues such as user fees.
The approach to addressing user fees is not precaution,but immediate
action. Utilisation changes will inevitably put pressure on the public
health systems, but then the issue, as pointed out in the conluding
section of the Chris James et al article is that the cost recovery of
implementing user fees are not that significant and yet transation costs,
often ignored in the whole process, require a more critical assessment.
The toll in terms ill-health and death due to lack of access cannot surely
be a matter allowed to be prolonged because there is likely to be an
increase in health care demand and utilisation. Nothing stops the
suggested actions(already in process anyway) from being udertaken at the
same time as fees are removed. There are better ways and more equitable
mechanisms (both from a horitntal and vertical point of view) of
generating revenue and allocating resources than through the prohibitive
and inefficient user fee structure or mechanism. The more user fee
removals are delayed the worse off people become as associated ill -
health conditions worsen and aggravate the capacity of poor people to be
responsive to productivity changes and increased wealth creation.
Mukosha Bona Chitah,
Central Board of Health,
Haille Selassie Avenue,
Competing interests: No competing interests