Access of the poor to health care in Ecuador : experiences with user fee schemes

The study focuses on private voluntary and municipal organizations, excluding Ministry of Public Health facilities, most of which were on strike at the time of the study. Mechanisms to facilitate access to services included general fee subsidies, reduced fees for services in poorer locations, exemptions and reduced fees for certain services, means testing, sliding fee scales, waivers, special government funds, and fast track services. Key findings are as follows. (1) The choice and use of mechanisms, and the volume and value of waivers, tended to vary with whether or not providers relied heavily on fee revenues. (2) In the main, the providers studied lack policies to exempt vulnerable groups; instead, they charge for all services and use pricing structures or waiver mechanisms to make those services affordable. This model is likely to be most cost-effective for outpatients, with means testing restricted to expensive care, such as surgery or hospital stays. (3) In terms of administrative costs, it is important that high-salaried staff not make decisions on low-value waivers; a system to monitor the volume and value of waivers is also essential. In general, cost-effectiveness should be examined within the context of the user fee system as a whole. (4) Protecting service access for the poor and vulnerable under user fee schemes largely depends on the goal of the organization and the availability of external subsidies. Every provider must generate the funding it needs to provide good quality services to its target population. If the organization has a mission to provide care to the poor, and the poor are not able to cover the cost of the service, the funding shortfall must be covered from external subsidies or from profits made from serving those who can pay for services. In a competitive environment, the latter option is limited because patients will change providers if profit margins become too high. The availability of funding for services to the poor is thus highly dependent on the amount of external subsidy. However, the efficient and effective use of resources is also critical, since the unrecovered cost of services needed by the poor and vulnerable is generally much higher than the amount of external subsidies available. (5) Determining the demand for services, providing such services in a cost-effective way, and setting fee, exemption, and waiver policies that generate sufficient revenue are difficult tasks. Determining appropriate fee levels is key. High fees may lead to low service utilization in general, little use of services by the poor, or a high number of waivers, while free or very low fees may generate insufficient revenue to the detriment of service quality and consequently higher costs to patients if they have to seek elements such as tests and drugs outside the facility or visit another provider, or if recovery from illness is delayed. (6) In order to successfully determine fee, exemption, and waiver policies, providers must have clear goals about who they aim to serve and must have realistic service and financial plans based on the epidemiological and economic profile of the catchment population. They must also have effective monitoring systems to determine if goals and targets are being achieved. None of the providers visited in Ecuador have all these elements in place, and they are unable to determine on an ongoing basis if they are meeting the need to protect the poor. (Author abstract, modified)