Financial risk protection – how do the informally employed pay for medical treatment? when health insurance is concluded. At the same time, sale of assets and indebtedness shrinks. 3.3 FINANCING MEDICAL CARE: IS THERE A GENDER BIAS? At first sight, it may be surprising that burdensome forms of health funding do not fully vanish with the availability of health insurance and many are still forced to sell assets or go into debt. Two issues have to be mentioned:(a) health insur­ance is hardly all-inclusive but limited to a certain number of illnesses and forms of treatment; those not included still have to be paid out-of-pocket;(b) the survey asked categorically about the sources of funding and not about the magnitude of the amounts. If the scale of asset sale or loans taken out had been included, we may have found insurance card holders reporting lower levels of burdensome funding than non-card holders. Insurance membership may thus reduce liabilities from health treatment even more than our data show. 3.2 FINANCING MEDICAL CARE: THE URBAN–RURAL DIVIDE If respondents are grouped according to urban or rural res­idence the modes of payment for medical treatment vary (see Figure 3.3). Discrepancies can be summarized as follows: – In Zambia and Kenya, there are more rural than urban dwellers who benefit from medical treatment at no cost. While free treatment schemes established by the gov­ernment may not give preference to rural people, NGO projects and confession-based initiatives may do so. – With the exception of Côte d’Ivoire, urban dwellers have a higher share in financing medical expenditures from own savings. The reason may be higher cash income and closer integration into the cash economy. – Mobilizing funds from burdensome sources concerns smaller groups in both urban and rural Zambia but in other countries both segments of the population are strongly affected. The sources for mobilizing discrimina­tory funds differ strongly, however. Patients from rural areas are more involved in selling assets, while patients from urban locations have a higher tendency to go for a cash loan. The key differences between urban and rural residents in settling their health bills appear to be linked to the mode of production. A majority of rural dwellers are peasants who own some land, farming equipment or agricultural produce which they may mortgage or sell to obtain cash for medical treatment, while urban residents have less property and are forced to go into debt when the need arises for medical treatment. Both modes of mobilizing funds put a financial strain on patients afterwards. With our data we are not able to follow up on the negative effects and conclude whether rural people have more aftermath stress than urban people do. However, our data clearly show that the high level of financing health costs from the sale of assets and obtaining loans is a heavy financial burden for both groups. Selling productive assets or plunging into debt to pay for medical treatment becomes an economic liability for the future and may chain households to a cycle of poverty. Are these threats contingent on whether paying for medical treatment involves a male or a female-led household? The breakdown of the sample into male and female-led households is shown in Figure 3.4. No significant differences are discernible in Senegal and Côte d’Ivoire. Zambia, Kenya and Ethiopia, however, appear to provide better access for female-led households to free medical care and make them to rely less on health funding from asset sales or loans. Our findings point to the existence of programmes and policies in three out of five countries which are aimed at reducing out-of-pocket payments and are more beneficial for female-led households. Confirmation of such effects would require a more detailed analysis than is possible here, however. 3.4 FINANCING MEDICAL CARE: THE INCOME FACTOR The level of income may be linked to the various modes of financing medical care in different ways. If medical care is provided free of charge, it may or may not take income level into account. If the scheme has universal coverage, however, households with higher incomes have the same entitlement as the poor. Where such schemes do not exist, patients from better-off households are more likely to visit medical facilities with insurance cover and have their bills paid. On the other hand, the better-off may opt against free services because of quality concerns and go for more elaborate medical care, for which they have to pay. The link between income level and the use of own savings is more straightforward. Households with higher per capita incomes have a higher capacity to save and are more likely to be able to pay for medical services from their own pocket. The same can be said about the use of incriminatory forms of financing. When earnings go up, the need to sell assets or go for a loan declines. The results are shown in Figure 3.5. To identify the effects of income inequality on the modes of payment for medical care, respondents are grouped into four income levels, which are defined as multiples of the statutory minimum wage. 1 No link is discernible between income inequality and access to free services, with the exception of Zambia. As free primary health care in Zambia has a universal character and does not prevent the better-off from accessing it, many appear to disregard it. We can therefore assume that patients with 1 Ethiopia has no statutory minimum wage. We used the 1,500 Birr as income reference and established similar income boundaries. 21