Global Health Watch 1 in one file

were in debt primarily because of paying for health care (Ensor and Pham
1996). Patients who borrow money to pay for treatment can end up paying
extortionate interest rates. To offset the cost of borrowing, households may
cut down on their food consumption, sell off precious assets such as land or
cattle, or withdraw children (particularly girls) from school to save on school
fees (Whitehead, Dahlgren and Evans 2001, Tipping 2000).
It is argued that exemption schemes can protect the poor from user fees.
But such schemes are rarely effective (Russell and Gilson 1997) and can encourage
extortion and patronage when service providers are poorly remunerated.
Neither is there any evidence that user fees prevent the ‘frivolous’ overuse of
health services – for most people, cost barriers result in an under-use of health
care services.
Given the evidence that user fees are a major and widespread barrier to
essential health care, as well as a cause of long-term impoverishment, it is
paradoxical that the poorer a country, the more likely its people will face outof-pocket
health care expenditure. In stark contrast, high-income countries
tend to have ‘socialized’ financing systems based on general taxation, national
health insurance or mandated social health insurance (Mackintosh and Koivusalo
2004).
the segmentation of health care systems The ‘segmentation of
health care systems’ refers to the phenomenon of separate health care systems
for richer and poorer people, as opposed to one universal health care
system for all. The World Bank in particular has advocated that governments
in poorer countries should focus their scarce public resources on providing
a free ‘basic’ or ‘minimum’ package of preventative and curative services for
the poor, while withdrawing from the direct provision of other services. By
encouraging the relatively rich sections of society to use the private sector,
it argues that the public sector will be able to redirect its resources to those
most in need (IFC 2002, Gwatkin 2003). In some middle- and high-income
countries, tax breaks on private insurance are used to entice higher-income
groups away from publicly provided services. Health care systems in some
countries are being segmented even further by the processes of globalization
– in India, Mexico and South Africa private providers cater to foreign ‘medical
tourists’ from high-income countries or from high-income groups in low- and
middle-income countries.
The assumption behind these policies is that it is more efficient and equitable
to segment health care according to income level – a public sector focused
on the poor and a private system for the rich that allows the public sector to
Approaches to health care
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