Abstract
BackgroundIt has been argued that quality improvements that result from user charges reduce their negative impact on utilization especially of the poor. In Uganda, because there was no concrete evidence for improvements in quality of care following the introduction of user charges, the government abolished user fees in all public health units on 1st March 2001. This gave us the opportunity to prospectively study how different aspects of quality of care change, as a country changes its health financing options from user charges to free services, in a developing country setting. The outcome of the study may then provide insights into policy actions to maintain quality of care following removal of user fees.MethodsA population cohort and representative health facilities were studied longitudinally over 3 years after the abolition of user fees. Quantitative and qualitative methods were used to obtain data. Parameters evaluated in relation to quality of care included availability of drugs and supplies and; health worker variables.ResultsDifferent quality variables assessed showed that interventions that were put in place were able to maintain, or improve the technical quality of services. There were significant increases in utilization of services, average drug quantities and stock out days improved, and communities reported health workers to be hardworking, good and dedicated to their work to mention but a few. Communities were more appreciative of the services, though expectations were lower. However, health workers felt they were not adequately motivated given the increased workload.ConclusionThe levels of technical quality of care attained in a system with user fees can be maintained, or even improved without the fees through adoption of basic, sustainable system modifications that are within the reach of developing countries. However, a trade-off between residual perceptions of reduced service quality, and the welfare gains from removal of user fees should guide such a policy change.
Highlights
It has been argued that there are quality improvements that result from user charges [1-5], which reduce their negative impact on utilization, especially by the poor [6]
Service quality has been hard to attain in many countries to a level that adequately compensates for the financial barrier set by user charges [7-10], many developing countries have maintained user charges inequitable
We have reviewed some aspects of quality of care that are likely to provide insights into overall quality changes following the abolition of user charges in health facilities in a developing country setting
Summary
It has been argued that quality improvements that result from user charges reduce their negative impact on utilization especially of the poor. In Uganda, because there was no concrete evidence for improvements in quality of care following the introduction of user charges, the government abolished user fees in all public health units on 1st March 2001. Service quality has been hard to attain in many countries to a level that adequately compensates for the financial barrier set by user charges [7-10], many developing countries have maintained user charges inequitable The justification for this has largely revolved around the need to support additional investment in primary health care and maintain quality services, even when costs are subsidized in the medium term by international aid and/or concessionary loans [11]. ** A HSD, which is headed by a hospital or an upgraded HC IV and located at a country level, serves an average population of 100,000 population It is a network of community-based health centers, which provides support to the lower-level health centers and manages referral cases.
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