Abstract
BackgroundUser fees have generally fallen out of favor across Africa, and they have been associated with reductions in access to healthcare. We examined the effects of the introduction and removal of user fees on outpatient attendances and new diagnoses of HIV, malaria, and tuberculosis in Neno District, Malawi where user fees were re-instated at three of 13 health centres in 2013 and subsequently removed at one of these in 2015.MethodsWe conducted two analyses. Firstly, an unadjusted comparison of outpatient visits and new diagnoses over three periods between July 2012 and October 2015: during the period with no user fees, at the re-introduction of user fees at four centres, and after the removal of user fees at one centre. Secondly, we estimated a linear model of the effect of user fees on the outcome of interest that controlled for unobserved health centre effects, monthly effects, and a linear time trend.ResultsThe introduction of user fees was associated with a change in total attendances of −68 % [95 % CI: −89 %, −12 %], similar reductions were observed for new malaria and HIV diagnoses. The removal of user fees was associated with an increase in total attendances of 352 % [213 %, 554 %] with similar increases for malaria diagnoses. The results were not sensitive to control group or model specification.ConclusionsUser fees for outpatient healthcare services present a barrier to patients accessing healthcare and reduce detection of serious infectious diseases.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1856-x) contains supplementary material, which is available to authorized users.
Highlights
User fees have generally fallen out of favor across Africa, and they have been associated with reductions in access to healthcare
Study background and context In Neno District, Malawi the health care infrastructure consists of 13 different healthcare facilities: eight are operated by the Ministry of Health, one private facility operated by a local electric company, and four are administered by Christian Health Association of Malawi (CHAM)
Attendances remained at 97 % of the pre-user fee level, on average, at Ministry of Health centres over the same two periods
Summary
User fees have generally fallen out of favor across Africa, and they have been associated with reductions in access to healthcare. In an analysis of 56 intergovernmental and international non-governmental organizations, government agencies, and other networks, There have been a number of studies examining the consequences of introducing or removing user fees, in sub-Saharan Africa [7]. These generally suggest increased utilization with the abolition of user fees, or a reduction in utilization with their introduction, the quality of the evidence has Watson et al BMC Health Services Research (2016) 16:595 been questioned [7,8,9,10,11,12]. Many studies indicate that user fees have a greater impact in poor populations, there is general agreement that in addition to user fees there are other barriers for the poor that need addressing [4, 13, 15]
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