Witter Sophie
Immpact, University of Aberden, UK.
Adv Health Econ Health Serv Res. 2009;21:251-88.
The first wave of experiences of exemptions policies suggested that poverty-based exemptions, using individual targeting, were not effective, for practical and political economic reasons. In response, many countries have changed their approach in recent years--while maintaining user fees as a necessary source of revenue for facilities, they have been switching to categorical targeting, offering exemptions based on high-priority services or population groups. This chapter aims to examine the impact and conditions for effectiveness of this recent health finance modality.
METHODOLOGY/APPROACH: The chapter is based on a literature review and on data from two complex evaluations of national fee exemption policies for delivery care in West Africa (Ghana and Senegal). A conceptual framework for analysing the impact of exemption policies is developed and used. Although the analysis focuses on exemption for deliveries, the framework and findings are likely to be generalisable to other service- or population-based exemptions.
The chapter presents background information on the nature of delivery exemptions, the drivers for their use, their scale and common modalities in low-income countries. It then looks at evidence of their impact, on utilisation, quality of care and equity and investigates their cost-effectiveness. The final section presents lessons on implementation and implications for policy-makers, including the acceptability and sustainability of exemptions and how they compare to other possible mechanisms.
The chapter concludes that funded service- or group-based exemptions offer a simple, potentially effective route to mitigating inequity and inefficiency in the health systems of low-income countries. However, there are a number of key constraints. One is the fungibility of resources at health facility level. The second is the difficulty of sustaining a separate funding stream over the medium to long term. The third is the arbitrary basis for selecting high-priority services for exemption. The chapter therefore concludes that this financing mode is unstable and is likely to be transitional.
第一轮豁免政策的经验表明，基于贫困的豁免（采用个体定位方式）由于实际和政治经济原因而效果不佳。作为回应，近年来许多国家改变了做法——在将使用者付费作为设施必要收入来源的同时，转向了类别定位，根据高优先级服务或人群提供豁免。本章旨在研究这种最新的卫生筹资模式的影响及有效条件。
方法/途径：本章基于文献综述以及对西非两国（加纳和塞内加尔）国家分娩护理费用豁免政策的两项综合评估数据。构建并运用了一个分析豁免政策影响的概念框架。尽管分析聚焦于分娩豁免，但该框架和研究结果可能适用于其他基于服务或人群的豁免。
本章介绍了低收入国家分娩豁免的性质、使用原因、规模及常见模式的背景信息。接着考察了其对利用率、护理质量和公平性的影响证据，并研究了其成本效益。最后一部分介绍了实施方面的经验教训及对政策制定者的启示，包括豁免的可接受性和可持续性，以及它们与其他可能机制的比较。
本章得出结论，有资金支持的基于服务或群体的豁免为减轻低收入国家卫生系统中的不公平和低效率提供了一条简单且可能有效的途径。然而，存在一些关键限制因素。一是卫生机构层面资源的可替代性。二是中长期维持单独资金流的困难。三是选择高优先级服务进行豁免的随意性。因此，本章得出结论，这种筹资模式不稳定，可能只是过渡性的。
