In rich countries, the government can fund the health system directly, or subsidise the health costs of its inhabitants through the social security system. People then only pay a small lump sum. But in low and mid-income countries, the government doesn't have the money for (almost) free healthcare. Cambodia, for instance, provides public health services, where people only pay a small lump sum. But in combination with travel costs, food costs and loss of income during the stay, this public system still is unaffordable for a lot of people. Moreover, it often is of bad quality: a wage of some fifty Euros a month doesn't stimulate a government doctor to do his best; it pushes him to have a sideline. So seven treatments out of ten are given in the private sector, where treatment is better but the prices are substantially higher. In these circumstances, becoming ill is a small catastrophe, leading to debts and bitter poverty.
Many governments try to provide the poor of the poor with at least a minimal health care through special programs. Cambodia distributes vouchers (that buy you a certain service) and has Health Equity Funds. These funds take care of lump sums, travel costs, food and other hospitalisation costs of the poor. They mostly are funded by international donors. Little research has been done into their effectiveness. Por Ir did more than ten years research in the field, trying to fill this gap. His conclusion: the vouchers and funds work well, though some problems remain.
How do you ensure for instance that the support goes to the poor, and not to friends and those prepared to bribe? Cambodia demonstrates it can be done: register durable goods, houses, land ownership. Such a registry makes people aware they are entitled to aid, but Por Ir found a weak spot, too: at the moment you become ill, your situation can be different from when you were registered. A quick check when people present themselves at the hospital can take care of that.
The funds work satisfactory in regions with a well functioning health service, where most people can afford a small lump sum (so the fund can focus on a manageable number of really poor), and where the funds are managed by a NGO (so lowly paid civil servants are not put to temptation).
At first the funds only paid for hospital admissions; as a consequence people directly presented at the hospitals, bypassing the first line. Now the government works to extend the coverage to family doctors and health centres.
Ir's research shows that the poor need specific care: they more often suffer from tropical infections as typhoid fever, tuberculosis, malaria, dengue; but also heart problems are very common among the poor (probably due to an imbalanced diet). Clearly overrepresented are traffic accidents and pregnancy problems.
Por Ir also signals another problem: when care for chronic diseases is almost nonexistent, you will not be able to buy it, whatever support you receive.
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