Here we discuss aspects of health services financing particular to scaling up rural primary healthcare services.

Overall Mission

Nyaya aims to work with local communities in Achham and the national government of Nepal to achieve a healthcare system that provides high-quality care to the poorest citizens while being financially sustainable. Local ownership over healthcare is paramount to ensuring quality and equity, yet complete local financing is impossible given that per-capita income is less than 50 cents per day. The Nepal government has a critical role to play in providing financing to ensure that all its citizens have access to health, yet, owing to war and geography, it has not adequately invested in Achham. As such, we must achieve sustainable sources of funding from international and national sources. We are literally starting from scratch; our medical clinic employed the first doctor for a district of 250,000 people.

The Issue of User Fees

Philosophically and practically, we are generally skeptical of charging patients user fees at the point of care. Although this is widely practiced throughout the world and in South Asia in particular, we have the following reservations:

• our concern of the one person who can't afford it justifies treating 50 minor issues (keeping it nominal and never turning away someone who says that can't pay would minimize)
• our belief that everyone should see a primary care provider even if they didn't have obvious acute complaints (even in the initial "acute, treatable, measurable" scale-up phase (see Triage)
• keeping it simple for the community by telling them to come for free services. this helps to build trust and clarity in the nascent health system.

An Alternative Strategy for Decreasing Initial Demand

In the initial phases of rolling out services in a place where there was a no system, we were flooded with a massive demand for our free services. Rather than user fees, our solution was to eliminate free provision of three major symptomatic treatments:

• analgesics/NSAIDS for lower back pain
• PPIs/H2s for GERD
• anti-histamines for URTIs

For these conditions, we have screening protocols for (Triage) and prescribe but do not dispense the symptomatic treatments. Patients can go to the private paramedical providers to fill the prescription.

The decreased flow that we subsequently saw is "good" only in so far as we are not equipped to deal with 150 patients and still nail those "treatable, measurable" conditions (Triage) and be a serious ANC/safe delivery center. Hopefully eventually we can manage the high patient flow and we can offer them some serious evidence-based preventive primary care. The impact of this strategy on our pharmaceutical expenditures was impressive; this can be viewed at our pharmacy data page.

Still being a 100% free clinic without user/registration fees but not providing free purely symptomatic/non-disease-altering treatments:

Pros/benefits

• consistency of message to the community: we are not out to make money but we provide free medicines for a certain number of conditions
• simplified accounting
• focus of community/government and donor funds on measurable, treatable conditions
• potential for a less antagonistic/competitive initial stance towards the paramedical "quacks" (because they do have some standing in the community and because they can help with referral of serious patients as long as they can still make their living with the symptomatic treatments)
• the system guarantees everyone free evaluation from a physician, but only provides medicines to certain conditions that we can really make an impact on.

Cons/dangers

• need to ensure that we don't lose the ultimate vision of an actual primary care system
• need to ensure that the screening process is rigorous and does not miss any danger signs that would warrant investigation into a more "organic/treatable" cause
• have to emphasize to staff that it is not that we don't feel their symptoms are "real"-- they are real we just aren't equipped to provide everything for free. We also need to provide adequate counseling and lifestyle modifications for these conditions.
• allow paramedical "quack" providers to continue to overcharge patients with their sketchy, sometimes expired medicines. Supporting these providers who do very little for the common good is a major issue.

The Need for Sustainable Financing

We are, however, interested in creating sustainable financing mechanisms that don't depend on charity or on the whims of grantors. For starting, we of course are using a 100% charity model where we provide free services using funds raised through EquityEdit, institutional grants, or our various fundraising activities. Long-term, however, we would like to develop a different model. Our motivation stems from some empirical literature that demonstrate that point-of-care user fees are a major deterrant to the timely access of preventive and curative medical treatments for the poorest patients. Furthermore, the dogma in Nepal, from both the mission hospitals and the government is that user fees are important to: decrease the number of "minor" or "superfluous" visits; improve adherence-- patients will value treatment that they pay for; and sustainability. We have not found much support for the first two claims; it is the third that we here seek to address.

The role of community ownership

We do agree that the community itself can play a role in financing their healthcare. This fundamentally is about improving the accountability and responsiveness of the healthcare system. Part of the problem with why both government- and NGO-run health systems suffer from vacant postings, expired medicines, and project terminations is that the community doesn't have negotiating power. Controlling finances to some extent (even if in partnership with central government, charity, and private insurance schemes) can potentially improve the situation. We propose, however, that these finances should not be shouldered by sick patients when they are trying to decide between feeding their families or accessing timely medical care.

P2P External Fundraising

One strategy would be to work on some model combining community-based health insurance with IT-based p2p funding like kiva.org to have a sustainable financing scheme for patients that doesn't charge user fees at the point-of-care. Although kiva.org is fantastic for many things, most of the health-related projects on kiva.org are to fund private pharmacists and practitioners, which we have seen in our work to be part of the problem.

The following are comprehensive discussions of various financing methods we could potentially use to help generate income for Nyaya as well as for villagers themselves.

Community Based Health Financing

P2P Funding of Specific Referral Cases

Integrating Microfinance into Clinic Funding

Using and Expanding Upon the Resources of Established Local Groups and COOPs

Alternative Financing Methods

Member Notes

one final product of your work should be a series of proposals (or planned proposals that we can take (or prepare to take) to different granting orgs and other collaborators. some key folks to "pitch" to eventually (might be in a year, but for something to shoot for):

http://www.digitalpartners.org/

kiva.org

http://www.desicrew.in/

http://www.grameenfoundation.org/what_we_do/technology_programs/

http://www.drishtee.com/

www. READGlobal.org

https://www.microplace.com/ ebay's for-profit alternative to kiva

http://www.worldchanging.com/archives/007470.html

additional links:

http://www.nextbillion.net/

microfinance consortium in nepal: http://www.cmfnepal.org/new/?pg=pub

health insurance in india e-book, comprehensive description of private market: http://www.healthinsuranceindia.org/default.asp