Abolition Of User Fees Research Articles

Health Financing Reforms in Uganda: Dispelling the Fears and Misconceptions Related to Introduction of a National Health Insurance Scheme Comment on "Health Coverage and Financial Protection in Uganda: A Political Economy Perspective".

Uganda introduced health financing reforms that entailed abolition of user fees, and in due process planned to introduce a National Health Insurance Scheme (NHIS). This paper accentuates a contextual and political-economic analysis that dispels the fears and misconceptions related to introduction of the insurance scheme. The Grindle and Thomas model is used to depict how various factors affect decision making by policy elites concerning a particular policy at a particular time. Drawing lessons from the sub-Sahara region and in particular, Ghana and Rwanda's experience, it is clear that the political will of the executive led by the president in many countries is a key determinant in bringing about health reforms. In this paper, we provide insights based on contextual and political-economic analysis to countries in similar setting that are interested in setting up NHISs.

From fees to free: User fee removal, maternal health care utilization and child health in Zambia

Despite recent progress, about 295,000 women in the World still die each year from pregnancy-related causes, and about 4.1 million children die before reaching the age of one. 99% of these deaths occur in developing countries. In 2006 the Zambian government removed user fees in public and mission health facilities in 54 out of 72 districts, and then extended this policy to rural parts of unaffected districts in 2007. I exploit the staggered implementation of the policy to assess its impact on maternal health care utilization and child health outcomes. Using a difference-in-differences estimation strategy, I find a 43% increase in the probability to give birth in a medical facility following the removal and a 36% increase in the probability of being assisted by a skilled birth attendant during childbirth. These positive effects decrease with household’s distance from the nearest health facility. In terms of child health, chronic malnutrition decreased by 8% and the abolition of user fees reduced newborn mortality risk only for those living close to a health facility providing essential emergency obstetric care and child health services. Access improved but returns to formal health services remained rather limited, highlighting the importance of addressing supply-side constraints to generate substantial gains in population health.

Women\u2019s decision-making power in a context of free reproductive healthcare and family planning in rural Burkina Faso

BackgroundIn 2016, the national user fee exemption policy for women and children under five was introduced in Burkina Faso. It covers most reproductive healthcare services for women including prenatal care, delivery, and postnatal care. In subsequent years, the policy was gradually extended to include family planning. While studies have shown that user fee abolition policies increase visits to health centers and improve access to reproductive healthcare and family planning, there are also indications that other barriers remain, notably women’s lack of decision-making power. The objective of the study is to investigate women’s decision-making power regarding access to reproductive health and family planning in a context of free healthcare in rural Burkina Faso.MethodsA descriptive qualitative study was carried out in rural areas of the Cascades and Center-West regions. Qualitative data were collected using individual semi-structured interviews (n = 20 participants) and focus groups (n = 15 participants) with Burkinabe women of childbearing age, their husbands, and key informants in the community. Data was analyzed using thematic analysis.ResultsA conceptual framework describing women’s participation in the decision-making process was built from the analysis. Results show that the user fee exemption policy contributes to improving access to reproductive care and family planning by facilitating the negotiation processes between women and their families within households. However, social norms and gender inequalities still limit women’s decision-making power.ConclusionIn light of these results, courses of action that go beyond the user fee exemption policy should be considered to improve women’s decision-making power in matters of health, particularly with regard to family planning. Interventions that involve men and community members may be necessary to challenge the social norms, which act as determinants of women’s health and empowerment.

National user fee abolition and health insurance scheme in Burkina Faso: How can they be integrated on the road to universal health coverage without increasing health inequities?

National user fee abolition and health insurance scheme in Burkina Faso: How can they be integrated on the road to universal health coverage without increasing health inequities?

Soins de santé gratuits pour les uns, payants pour les autres : perceptions et stratégies d’adaptation dans le district de Boulsa (Burkina Faso)

Contexte : Les preuves des bienfaits des politiques de gratuité des soins sont réunies, mais les enjeux éthiques que ces politiques soulèvent dans les pays à faibles revenus ont été peu examinés. Au Burkina Faso, la gratuité a été introduite en juillet 2016 pour les enfants de moins de 5 ans et les femmes enceintes, en ce qui concerne les soins en santé reproductive. Il a été rapporté que les critères d’éligibilité sont parfois difficiles à interpréter ou à mettre en application. L’objectif de cette étude est double : 1) comprendre les perceptions et les pratiques du personnel de santé et des bénéficiaires à l’égard du respect des critères d’éligibilité à la gratuité et 2) explorer les tensions éthiques qui en ont découlé et les éventuels modes de résolution. Méthodologie : En 2018, une étude qualitative transversale a été menée dans cinq communautés rurales de Boulsa, au Burkina Faso, Des entrevues individuelles semi-dirigées ont été réalisées auprès du personnel soignant (n=10) et de mères de jeunes enfants (n=10), qui ont été sélectionnées avec l’aide d’agents de santé à base communautaire. Les enregistrements audios ont été traduits et retranscrits. Une analyse thématique de contenu a été réalisée sur l’ensemble du matériel. Les thèmes qui sont ressortis de l’analyse thématique ont été identifiés par les membres de l’équipe, qui en ont discuté et les ont reformulés. Résultats : L’étude suggère que les critères d’éligibilité à la gratuité ne sont pas toujours bien connus des bénéficiaires, ce qui peut entraîner des débordements involontaires. Elle révèle aussi l’adoption de pratiques pour contourner le respect strict des critères d’éligibilité à la gratuité, notamment pour en faire bénéficier les enfants de 5 ans et plus. Ces débordements délibérés résultent de tensions éthiques vécues par les bénéficiaires, et en soulèvent d’autres chez le personnel soignant. Des mécanismes sont mis en oeuvre officieusement pour réconcilier les dissonances ressenties par les prestataires. Conclusion : La mise en oeuvre de la politique de gratuité au Burkina Faso s’opère grâce à des mécanismes de réinvention locale pour surmonter les tensions éthiques liées au respect des critères d’éligibilité.

Out-of-pocket expenditure for home and facility-based delivery among rural women in Zambia: a mixed-methods, cross-sectional study.

PurposeOut-of-pocket expenses associated with facility-based deliveries are a well-known barrier to health care access. However, there is extremely limited contemporary information on delivery-related household out-of-pocket expenditure in sub-Saharan Africa. We assess the financial burden of delivery for the most remote Zambian women and compare differences between delivery locations (primary health center, hospital, or home).MethodsWe conducted household surveys and in-depth interviews among randomly selected remote Zambian women who delivered a baby within the last 13 months. Women reported expenditures for their most-recent delivery for delivery supplies, transportation, and baby clothes, among others. Expenditures were converted to US dollars for analysis.ResultsOf 2280 women sampled, 2223 (97.5%) reported spending money on their delivery. Nearly all respondents in the sample (95.9%) spent money on baby clothes/blanket, while over 80% purchased delivery supplies such as disinfectant or cord clamps, and a third spent on transportation. Women reported spending a mean of USD28.76 on their delivery, with baby clothes/blanket (USD21.46) being the main expenditure and delivery supplies (USD3.81) making up much of the remainder. Compared to women who delivered at home, women who delivered at a primary health center spent nearly USD4 (p<0.001) more for their delivery, while women who delivered at a level 1 or level 2 hospital spent over USD7.50 (p<0.001) more for delivery.ConclusionThese expenses account for approximately one third of the monthly household income of the poorest Zambian households. While the abolition of user fees has reduced the direct costs of delivering at a health facility for the poorest members of society, remote Zambian women still face high out-of-pocket expenses in the form of delivery supplies that facilities should provide as well as unofficial policies/norms requiring women to bring new baby clothes/blanket to a facility-based delivery. Future programs that target these expenses may increase access to facility-based delivery.

\u201cWays and channels for voice regarding perceptions of maternal health care services within the communities of the Makamba and Kayanza provinces in the Republic of Burundi: an exploratory study\u201d

BackgroundIncreased availability of maternal health services alone does not lead to better outcomes for maternal health.The services need to be utilized first.One way to increase service utilization is to plan responsive health care services by taking into account the community’s views or expressed needs.Burundi has a high maternal mortality ratio, and despite improvements in health infrastructure, skilled staff and the abolition of user fees for pregnant women,utilization of maternal health services remains low. Possible reasons for this include a lack of responsive healthcare services.An exploratory study was conducted in 2013 in two provinces of Burundi (Makamba and Kayanza), with the aim to collect the experiences of women and men with the maternal health services,their views regarding those services, channels used to express these experiences, and the providers’ reaction.MethodsSemi-structured interviews were used to collect data from men and women and key informants, including community health workers, health committee members, health providers, local authorities, religious leaders and managers of non-governmental organizations. Data analysis was facilitated by MAXQDA 11 software.ResultsNegative experiences with maternal health services were reported and included poor staff behavior towards women and a lack of medicine. Health committees and suggestion boxes were introduced by the government to channel the community’s views. However, they are not used by the community members, who prefer to use community health workers as intermediaries. Fear of expressing oneself linked to the post-war context of Burundi, social and gender norms, and religious norms limit the expression of community members’ views, especially those of women. The limited appreciation of community health workers by the providers further hampers communication and acceptance of the community’s views by health providers.ConclusionIn Burundi, the community voice to express views on maternal health services is encountering obstacles and needs to be strengthened,especially the women’s voice. Community mobilization in the form of a mass immunization campaign day organized by women fora, and community empowerment using participatory approaches could contribute towards community voice strengthening.

User Fee Abolition and the Demand for Public Health Care

AbstractThis research examines the effect of the abolition of user fees in South Africa, a policy implemented in 1994 for uninsured children under the age of six and the elderly uninsured, as well as pregnant and nursing mothers. The analysis focuses on the implementation of the policy and the use of curative public healthcare services by children following strict and fuzzy regression discontinuity designs. The estimates point to statistically insignificant average and local average policy effects, even though the policy appears to have been implemented reasonably effectively, albeit imperfectly. In other words, the policy did not, on average, affect the use of curative public healthcare, at least for those children who should have benefited from the policy.

Healthcare Facility Choice and User Fee Abolition: Regression Discontinuity in a Multinomial Choice Setting

Summary We apply parametric and non-parametric regression discontinuity methodology within a multinomial choice setting to examine the effect of public healthcare user fee abolition on health facility choice by using data from South Africa. The non-parametric model is found to outperform the parametric model both in and out of sample, while also delivering more plausible estimates of the effect of user fee abolition (i.e. the ‘treatment effect’). In the parametric framework, treatment effects were relatively constant—around 10%—and that increase was drawn equally from home care and private care. In contrast, in the non-parametric framework treatment effects were largest for large (and poor) families located further from health facilities—approximately 5%. More plausibly, the positive treatment effect was drawn primarily from home care, suggesting that the policy favoured children living in poorer conditions, as those children received at least some minimum level of professional healthcare after the policy was implemented.

From institutionalization of user fees to their abolition in West Africa: a story of pilot projects and public policies.

This article analyzes the historical background of the institutionalization of user fees and their subsequent abolition in West Africa. Based on a narrative review, we present the context that frames the different articles in this supplement. We first show that a general consensus has emerged internationally against user fees, which were imposed widely in Africa in the 1980s and 1990s; at that time, the institutionalization of user fees was supported by evidence from pilot projects funded by international aid agencies. Since then there have been other pilot projects studying the abolition of user fees in the 2000s, but these have not yet had any real influence on public policies, which are often still chaotic. This perplexing situation might be explained more by ideologies and political will than by insufficient financial capacity of states.

Trends in perinatal health indices in the Amajuba District, KwaZulu-Natal, South Africa, 1990 - 2012

Background. In order to address the high perinatal mortality rate, South Africa (SA) commenced a number of interventions from 1995. These included the abolition of user fees, basic antenatal care, on-the-spot diagnosis and treatment of syphilis, and the prevention of mother-to-child transmission of HIV. However, there is a dearth of information on the long-term effect of these programmes on perinatal indicators in district hospitals, where most births and deaths occur. Objective. To determine the levels and trends in maternal and neonatal indicators in Amajuba District, KwaZulu-Natal Province, SA, and to ascertain the dynamics of these indicators vis-a-vis the transformation of healthcare in SA. Methods. The study location was Madadeni Hospital and its nine feeder maternity clinics. Information pertaining to all deliveries and their outcome from these health facilities from 1990 to 2012 was extracted from the clinical registers. Data were analysed using SPSS version 15.0 (IBM, USA). Quantitative variables were summarised as means, while qualitative data were expressed as proportions and percentages. The trends for each outcome variable for the entire study period (1990 - 2012) were analysed and presented as line graphs and tables. Results. There were 154 821 live births and 4 133 stillbirths from 1990 to 2012. The overall mean values for stillbirth rate, perinatal mortality rate, neonatal mortality rate and maternal mortality ratio were 26.3 (standard deviation 5.6), 40.9 (9.6), 16.8 (4.7) and 114 (56.6), respectively. There was a general improvement in all the perinatal health indices in the early 90s, followed by a general worsening until the early 2000s, after which a consistent decline was noted. Conclusion. The perinatal health indices in Amajuba District have followed a pattern similar to that found in the rest of SA: an increase during the late 90s to early 2000s, followed by a decline from the late second half of the first decade of this century.

Improving financial access to health care in the Kisantu district in the Democratic Republic of Congo: acting upon complexity

BackgroundComzmercialization of health care has contributed to widen inequities between the rich and the poor, especially in settings with suboptimal regulatory frameworks of the health sector. Poorly regulated fee-for-service payment systems generate inequity and initiate a vicious circle in which access to quality health care gradually deteriorates. Although the abolition of user fees is high on the international health policy agenda, the sudden removal of user fees may have disrupting effects on the health system and may not be affordable or sustainable in resource-constrained countries, such as the Democratic Republic of Congo.Methods and ResultsBetween 2008 and 2011, the Belgian development aid agency (BTC) launched a set of reforms in the Kisantu district, in the province of Bas Congo, through an action-research process deemed appropriate for the implementation of change within open complex systems such as the Kisantu local health system. Moreover, the entire process contributed to strengthen the stewardship capacity of the Kisantu district management team. The reforms mainly comprised the rationalization of resources and the regulation of health services financing. Flat fees per episode of disease were introduced as an alternative to fee-for-service payments by patients. A financial subsidy from BTC allowed to reduce the height of the flat fees. The provision of the subsidy was made conditional upon a range of measures to rationalize the use of resources.ConclusionsThe results in terms of enhancing people access to quality health care were immediate and substantial. The Kisantu experience demonstrates that a systems approach is essential in addressing complex problems. It provides useful lessons for other districts in the country.

Did primary healthcare user fee abolition matter? Reconsidering South Africa's experience

South Africa waived user fees for primary healthcare in 1994 and, again, in 1996. The first waiver focused on young children, elderly adults, pregnant women and nursing mothers, while the 1996 reform waived fees for the remainder of the population, subject to means tests. We take advantage of household survey information to examine the impact of the policy on a subset of the reform-eligible population. Although it was expected that public healthcare facility usage would have increased post reform, no statistically significant evidence supported such a claim. Therefore, our results are consistent with some very recent research examining the 1994 reform, but are generally at odds with the general impression in the literature that user fee abolition matters when it comes to alleviating inequities in access to healthcare.

A qualitative study of health system barriers to accessibility and utilization of maternal and newborn healthcare services in Ghana after user-fee abolition.

BackgroundTo reduce financial barriers to access, and improve access to and use of skilled maternal and newborn healthcare services, the government of Ghana, in 2003, implemented a new maternal healthcare policy that provided free maternity care services in all public and mission healthcare facilities. Although supervised delivery in Ghana has increased from 47% in 2003 to 55% in 2010, strikingly high maternal mortality ratio and low percentage of skilled attendance are still recorded in many parts of the country.To explore health system factors that inhibit women’s access to and use of skilled maternal and newborn healthcare services in Ghana despite these services being provided free.MethodsWe conducted qualitative research with 185 expectant and lactating mothers and 20 healthcare providers in six communities in Ghana between November 2011 and May 2012. We used Attride-Stirling’s thematic network analysis framework to analyze and present our data.ResultsWe found that in addition to limited and unequal distribution of skilled maternity care services, women’s experiences of intimidation in healthcare facilities, unfriendly healthcare providers, cultural insensitivity, long waiting time before care is received, limited birthing choices, poor care quality, lack of privacy at healthcare facilities, and difficulties relating to arranging suitable transportation were important health system barriers to increased and equitable access and use of services in Ghana.ConclusionOur findings highlight how a focus on patient-side factors can conceal the fact that many health systems and maternity healthcare facilities in low-income settings such as Ghana are still chronically under-resourced and incapable of effectively providing an acceptable minimum quality of care in the event of serious obstetric complications. Efforts to encourage continued use of maternity care services, especially skilled assistance at delivery, should focus on addressing those negative attributes of the healthcare system that discourage access and use.

Uptake of evidence in policy development: the case of user fees for health care in public health facilities in Uganda.

BackgroundSeveral countries in Sub Saharan Africa have abolished user fees for health care but the extent to which such a policy decision is guided by evidence needs further exploration. We explored the barriers and facilitating factors to uptake of evidence in the process of user fee abolition in Uganda and how the context and stakeholders involved shaped the uptake of evidence. This study builds on previous work in Uganda that led to the development of a middle range theory (MRT) outlining the main facilitating factors for knowledge translation (KT). Application of the MRT to the case of abolition of user fees contributes to its refining.MethodsEmploying a theory-driven inquiry and case study approach given the need for in-depth investigation, we reviewed documents and conducted interviews with 32 purposefully selected key informants. We assessed whether evidence was available, had or had not been considered in policy development and the reasons why and; assessed how the actors and the context shaped the uptake of evidence.ResultsSymbolic, conceptual and instrumental uses of evidence were manifest. Different actors were influenced by different types of evidence. While technocrats in the ministry of health (MoH) relied on formal research, politicians relied on community complaints. The capacity of the MoH to lead the KT process was weak and the partnerships for KT were informal. The political window and alignment of the evidence with overall government discourse enhanced uptake of evidence. Stakeholders were divided, seemed to be polarized for various reasons and had varying levels of support and influence impacting the uptake of evidence.ConclusionEvidence will be taken up in policy development in instances where the MoH leads the KT process, there are partnerships for KT in place, and the overall government policy and the political situation can be expected to play a role. Different actors will be influenced by different types of evidence and their level of support and influence will impact the uptake of evidence. In addition, the extent to which a policy issue is contested and, whether stakeholders share similar opinions and preferences will impact the uptake of evidence.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-014-0639-5) contains supplementary material, which is available to authorized users.

What criteria guide national entrepreneurs' policy decisions on user fee removal for maternal health care services? Use of a best-worst scaling choice experiment in West Africa.

Several countries in sub-Saharan Africa have implemented policies to remove or reduce user fees. Our aim was to identify criteria guiding such decisions among national policy entrepreneurs, those who link up problem definition, solution development and political processes. We administered a best-worst scaling (BWS) experiment to 89 policy entrepreneurs, asking them to identify the most and the least important criteria on a series of predefined sets. Sets were compiled using a Balance Incomplete Block Design which generated random combinations of all 11 criteria included in the experiment. In turn, those had emerged from a prior set of focus group discussions organized among policy entrepreneurs. Ordered logit models were used to investigate the value of single criteria as well as heterogeneity of preferences. Political commitment was identified as the most important criterion guiding policy decisions on user fee abolition or reduction to the overall sample, but particularly so for more experienced respondents aged over 50 years. International pressure and donor money were identified as least important while equity and institutional capacity were deemed of relatively little importance. Respondents more involved in advising on policy than on formulating policy rated economic issues such as financial sustainability and cost-effectiveness as less important. It is feasible to apply BWS experiments in low-income countries, although whether the technique can be adjusted to elicit preferences among non-literate respondents in these settings is unclear.

Present status and possibilities for elimination of user fees in Slovenian public libraries

ABSTRACTThe article presents the status and possibilities for abolition of user fees in Slovenian public libraries. Key international documents IFLA/UNESCO Public Library Manifestand Guidelines for Public Library Service define professional position on this issue. Pete Giacoma elaborates user fees from different perspectives such as economic theories, political consensus and equity. Legal framework for user fees in Slovenia is described and the study draws attention to its inconsistency. The legal framework, level of membership fees, percentage of registered borrowers etc. are compared with several European countries. Data on user fees in Slovenian public and academic libraries, museums and galleries were collected and compared. Differences among public libraries are shown regarding the structure and level of general income and income from user fees. Structure of expenditure is also presented and potential loss of income is assessed. Library directors expressed their views on consequences of proposed membershipfee elimination. The survey ends with the proposal for next action steps towards successful governance of this problem.

Global health actors no longer in favor of user fees: a documentary study.

BackgroundSince the advent of health user fees in low- and middle-income countries in the 1980s, the discourse of global health actors (GHAs) has changed to the disadvantage of this type of healthcare financing mechanism. The aim of the study was to identify and analyze the stance of GHAs in the debate on user fees.MethodsWe conducted documentary research using public documents published by and officially attributed to GHAs from 2005 to 2011. We categorized GHAs into four groups: intergovernmental organizations, international non-governmental organizations, government agencies, and working groups and networks. We then classified the GHAs according to their stance relative to the abolition of user fees, and conducted a thematic analysis of their discourse to understand the arguments used by each GHA to justify its stance.ResultsWe identified 56 GHAs, for which we analyzed 140 documents. Among them, 55% were in favor of the abolition of user fees or in favor of free care at the point of delivery. None of the GHAs stated that they were in favor of user fees; however, 30% did not take a stand. Only the World Bank declares that it is both in favor of user fees and in favor of free care at point of service. GHAs generally circumscribe their stance to specific populations (pregnant women, children under 5 years, etc.) or to specific health services (primary, basic, essential). Three types of arguments are used by GHAs to justify their stance: economic, moral and ethical, and pragmatic.ConclusionsThe principle of “user pays” seems to have fizzled. Production and dissemination of evidence, as well as certain advocacy networks, may have contributed to this change in discourse. However, GHAs should go a step further and translate their words into action, so that free healthcare at the point of delivery becomes a reality in low- and middle-income countries. They should provide technical and financial support to those countries that have chosen to implement user fee exemption policies, sometimes influenced by a GHA.

Hidden costs: The direct and indirect impact of user fees on access to malaria treatment and primary care in Mali

About 20 years after initial calls for the introduction of user fees in health systems in sub-Saharan Africa, a growing coalition is advocating for their removal. Several African countries have abolished user fees for health care for some or all of their citizens. However, fee-for-service health care delivery remains a primary health care funding model in many countries in sub-Saharan Africa. Although the impact of user fees on utilization of health services and household finances has been studied extensively, further research is needed to characterize the multi-faceted health and social problems associated with charging user fees. This ethnographic study aims to identify consequences of user fees on gender inequality, food insecurity, and household decision-making for a group of women living in poverty. Ethnographic life history interviews were conducted with 24 women in Yirimadjo, Mali in 2007. Purposive sampling selected participants across a broad socio-economic spectrum. Semi-structured interviews addressed participants' past medical history, socio-economic status, social and family history, and access to health care. Interview transcripts were coded using the guiding analytical framework of structural violence. Interviews revealed that user fees for health care not only decreased utilization of health services, but also resulted in delayed presentation for care, incomplete or inadequate care, compromised food security and household financial security, and reduced agency for women in health care decision making. The effects of user fees were amplified by conditions of poverty, as well as gender and health inequality; user fees in turn reinforced the inequalities created by those very conditions. The qualitative data reveal multi-faceted health and socioeconomic effects of user fees, and illustrate that user fees for health care may impact quality of care, health outcomes, food insecurity, and gender inequality, in addition to impacting health care utilization and household finances. As many countries consider user fee abolition policies, these findings indicate the need to create a broader evaluation framework—one that can measure the health and socioeconomic impacts of user fee polices and of their removal.

Accès au traitement préventif intermittent (TPI) dans une situation de gratuité : rôle du bien-être économique

In Senegal, the free distribution of sulfadoxine pyrimethamine during antenatal care is recommended to remove the disparity in the context of intermittent preventive treatment against malaria. The objective of this study was thus to identify factors influencing access to treatment in a situation of abolition of user fees. It was a cross-sectional and analytical study. It covered a sample of 1906 women aged 15–49 years randomly selected during the national survey on malaria in Senegal. Data were collected during a personal interview. The economic well-being was measured from the characteristics of housing and durable goods. The multivariate analysis was performed using logistic regression. The average age was 27.94 ± 5.34, 64.27% resided in rural area and 71.8% had received no schooling. Among the surveyed women, 23% were in the poorest quintile, while 16.3% were in the richest. Intermittent preventive treatment was performed in 49.3%. IPt were made more in urban areas (OR 1.45 95% [1.17 to 1.72]). It increased with the level of education with an OR of 1.5 and 1.68 in primary and secondary. The completion of the IPt increased with economic welfare. The OR ranged from 1.44 to 2.95 in the second quintile to the richest. Free medication does not necessarily benefit poor people. Other accompanying measures must be developed to facilitate the distribution of drugs particularly at community level with the involvement of people.