Xu Ke, Evans David B, Kadama Patrick, Nabyonga Juliet, Ogwal Peter Ogwang, Nabukhonzo Pamela, Aguilar Ana Mylena
World Health Organization, Geneva, Switzerland.
Soc Sci Med. 2006 Feb;62(4):866-76. doi: 10.1016/j.socscimed.2005.07.004. Epub 2005 Sep 1.
There is currently considerable discussion between governments, international agencies, bilateral donors and advocacy groups on whether user fees levied at government health facilities in poor countries should be abolished. It is claimed that this would lead to greater access for the poor and reduce the risks of catastrophic health expenditures if all other factors remained constant, though other factors rarely remain constant in practice. Accordingly, it is important to understand what has actually happened when user fees have been abolished, and why. All fees at first level government health facilities in Uganda were removed in March 2001. This study explores the impact on health service utilization and catastrophic health expenditures using data from National Household Surveys undertaken in 1997, 2000 and 2003. Utilization increased for the non-poor, but at a lower rate than it had in the period immediately before fees were abolished. Utilization among the poor increased much more rapidly after the abolition of fees than beforehand. Unexpectedly, the incidence of catastrophic health expenditure among the poor did not fall. The most likely explanation is that frequent unavailability of drugs at government facilities after 2001 forced patients to purchase from private pharmacies. Informal payments to health workers may also have increased to offset the lost revenue from fees. Countries thinking of removing user charges should first examine what types of activities and inputs at the facility level are funded from the revenue collected by fees, and then develop mechanisms to ensure that these activities can be sustained subsequently.
目前，政府、国际机构、双边捐助者和倡导团体之间正在就是否应取消贫穷国家政府医疗机构收取的用户费用展开大量讨论。据称，如果所有其他因素保持不变，取消用户费用将使穷人有更多机会获得医疗服务，并降低灾难性医疗支出的风险，不过在实际中其他因素很少保持不变。因此，了解取消用户费用后实际发生了什么以及原因很重要。乌干达在2001年3月取消了一级政府医疗机构的所有费用。本研究利用1997年、2000年和2003年进行的全国家庭调查数据，探讨了对医疗服务利用和灾难性医疗支出的影响。非贫困人口的医疗服务利用率有所提高，但增速低于取消费用前的时期。取消费用后，贫困人口的医疗服务利用率增长速度比之前快得多。出乎意料的是，贫困人口中灾难性医疗支出的发生率并未下降。最有可能的解释是，2001年之后政府医疗机构药品经常短缺，迫使患者从私人药店购买药品。向医护人员的非正式支付可能也有所增加，以抵消费用收入的损失。考虑取消用户收费的国家应首先审查医疗机构层面哪些类型的活动和投入是由收费收入资助的，然后制定机制以确保这些活动随后能够持续下去。
