FRIEDRICH-EBERT-STIFTUNG – A majority working in the shadows Figure 3.6 Use of medical care if funding has to come from asset sales or going into debt 70% 60% 50% 40% 30% 20% 10% 35.8% 59.8% 12.1% Sale of possesion or loan(any form) 45.5% 14.3% 27.1% 20.0% 37.3% 0% Regular Low use Regular Low use Regular Low use Regular Low use Use Use Use Use Senegal Zambia Kenya Côte d’Ivoire 40.1% 47.6% Regular Use Low use Ethiopia Income inequality thus works as expected: well-off house­holds are better able to pay their health care bills from avail­able savings, while poorer households are more often forced to sell property or go into debt. The negative effects are barely discernible for Zambia, however, where free primary health care clearly provides a shield against more burden­some forms of funding. Where there is no free medical treatment and medical bills cannot be paid from savings but only through either the sale of assets or from taking out a loan, the general reaction is predictable. People try to avoid medical treatment. This correlation is highlighted in Figure 3.6. With the exception of Zambia, where risky forms of financing medical treatment are less needed because of the free health care system, all countries manifest this link. If financial means have to be mobilised by selling assets or taking out loans, people tend to stay away from medical facilities and the use of medical care declines. In Senegal, 60 per cent of respondents who have to sell assets or go into debt declare that they rarely seek medical treatment. Kenya and Ethiopia report similarly high incidences of health service»boycotts« as a result of low incomes. 3.5 SUMMARY Our data provide insights into the self-assessed availability of medical care and the financial consequences resulting from having to pay health care bills. People who are forced to sell property or go into debt in order to source funds for medi­cal treatment will avoid visits to medical services whenever possible to prevent dire financial consequences. With the exception of Zambia, where risky sources are hardly used for covering medical bills, there is a clear negative interrela­tion between the capacity to pay with one’s own monetary reserves and the frequency with which medical facilities are visited. If dependence on external financing(asset sales and loans) goes up, the use of medical services goes down. Quite clearly, many poor people are forced to go without treatment not because medical services are not available but because they do not have the means to pay for them. REFERENCES WHO(website) Financial protection; available at: https://www.who.int/health-topics/financial-protection#tab=tab_1. – Global health expenditure database; available at: https://apps.who.int /nha /database/ ViewData/ Indicators/en We have no documentation on how many times the infor­mally employed or their family members were sick; how many times they visited medical centres; how serious the sickness was in each case; whether the kind of treatment actually received corresponded to the treatment needed; or whether patients»opted« for simple medical care because it was provided free instead of going for surgery and intensive but costly medical treatment. Such information would be needed to enable us to carry out a fully informed evaluation of the availability of quality medical care for all. Furthermore, we did not collect information about the level of health bills and how medical expenditures are related to income. Such information, again, would be needed for a de­tailed evaluation of the affordability of quality medical care. 24