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The downside of "free" health care

A woman with her children consulting a doctor at the community health centre in Abobo-Te, in the Ivoirian economic capital Abidjan. July 2011
(Nancy Palus/IRIN)

Côte d'Ivoire is studying national health insurance and other schemes for financing public health services so more people have access to quality care. For now the temporary policy of free care - which the government said was aimed to help people after the post-election crisis - is causing grief for doctors and patients alike.

Many women in the city who have recently taken their children to hospital, where medicines are scarce, told IRIN they would prefer a return to the country's long-time system of health user fees.

"At least we knew where we stood, and we could get some services," said Mariam* in Adjamé District. Now, women said, hardly any medicines or services are available; they said they suspect many health personnel simply do not want to provide services when no money is changing hands.

Whether health staff are denying services or simply cannot provide them for lack of equipment (many hospitals were looted during the fighting), the abrupt change to free public health services has hardly brought relief, health workers and Abidjan residents said.

Débé Mobio, a dental surgeon at the Abobo-Te community health centre, said he understands that patients are frustrated and their confidence in health workers - already shaky - has taken a hit. "Before many saw us as corrupt - now it's worse." 

Such a major shift (Côte d'Ivoire has long had a policy of cost recovery for health services) requires planning and input from doctors who are in touch with communities daily, Mobio and other staff at the Abobo-Te centre told IRIN.

"The problem with free health care is it was not prepared - we've all just fallen into this new system," said pharmacist Binaté Nouho. "At the beginning [when the policy was just announced and donors had given supplies] we had medicines, but they've all run out. We can do the consultations free but we don't have money to buy medicines... The system is jammed."

Expensive prescriptions

The situation gives people false hopes, health workers said. And doctors are left with the task of informing the patient of an ailment but then handing them an expensive prescription to be collected from a private pharmacy.

"There was not even a preliminary study into the needs before announcing free care, and it was just launched," said Kouadio Yves-Eric, a dental surgeon at the urban health centre in Affery, north of Abidjan.

"When a sick person comes it leads only to problems; he came to get free medical care but then finds himself with a prescription in hand, an expense he didn't expect to face. So you've created a health need and so the person has to go looking for the money, maybe go into debt, to go and buy that prescription.

"We now have this sort of phobia of facing our patients. Here they are before us and we strain to find the words to make them understand they've got to go buy the prescribed medicines."

On a recent afternoon staff at the Abobo-Te maternity ward tried to calm a pregnant woman moaning in pain as she waited for a family member to return with her prescription.

"In the past, before health services were free, we would have had at least the basics on hand to give her the initial care she needs and to ease her pain," said Yéo Assétou, a midwife at the health centre.

Community health centres like the one at Abobo-Te depend on fees to replenish medicines, pay some staff and buy products to clean the facility.

"Here we are attending births and most of the time we don't even have gloves," Yéo said.

The inability to pay some staff means that at the maternity ward experts are not on hand 24 hours a day as before, gynaecologist Kamagaté Matindé said. Still, she noted, even if there is a lack of medicines and staff, under the “free” health service more women are coming for prenatal consultations, which before cost 3,000 CFA francs (US$6.50).

Not sustainable

While the idea of free care to help people in the initial period after the crisis was laudable, the current situation is not sustainable, doctors said.

"It didn't bother us at all just after the crisis, when the government announced one month of free health care," oral surgeon Mobio said. "But when they prolonged it, we just didn't understand at all what was going on... and health workers' motivation plummeted. We should have all had a chance to sit and talk about how we're going to proceed - what we would have to do if we want to continue free care."

"Unfortunately we doctors were not even consulted," Kouadio told IRIN. "We also lived through the crisis, the psychological effects. Practising medicine - it's intellectual work. In my view we need a break of a couple of months to review all of this."

Health Ministry officials were unavailable for comment. The ministry held a meeting 14-15 July to discuss options like a national insurance scheme and other mechanisms to finance public health services.

Health workers point out that many problems in public health care are structural - management, organization, accountability - and must be addressed no matter how services are financed.

Last year Côte d'Ivoire was allocating about 5 percent of the national budget to health care - far short of the 15 percent African leaders pledged as part of the 2001 Abuja Declaration.

*Not her real name



This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions

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