Making choices between prepayment and user charges in Zambia. What are the results for equity?
研究了赞比亚预付费和折扣卡两种支付机制相对于用户收费对医疗服务可及性和公平性的影响，发现预付费能减少收入相关的公平损失，而折扣卡效果较弱。
In many low-income countries, user charges were introduced in the 1990s. As problems emerged of equity of access, interest grew in developing prepayment mechanisms to protect users from risk of out-of-pocket payments. In Zambia, a prepayment scheme did not generate sufficient revenue, due to abuses of its terms. An alternative scheme using discount cards (a set of coupons to cover episodes of care at discount) was devised. We aimed to understand the equity implications of prepayment and discount cards relative to user charges. We proposed models predicting roles of income, perceived health status, perceived quality of care and time preference in choice of payment mechanism and use of health services. We tested these models using three data sets that could be accessed or collected. It is concluded that relative to user charges, prepayment may facilitate access without incurring income-related equity losses. Evidence concerning discount cards was weaker. We concluded that they facilitate access to a lesser extent. Discount cards offer a credible intermediate solution between user charges and prepayment that avoid some problems associated with prepayment. However, since prepayment seems to be associated with the most positive outcomes, finding other solutions to their problems would be preferred.