High User Fees Research Articles

Provider and client perspectives on the use of maternity waiting homes in rural Rwanda

ABSTRACT Background The World Health Organization recommends the implementation of maternity waiting homes (MWH) to reduce delays in access to obstetric care, particularly for high-risk pregnancies and mothers living far from health facilities, and as a result, several countries have rolled out MWHs. However, Rwanda has not implemented this recommendation on a large scale. There is only one MWH in the country, hence a gap in knowledge regarding the potential utilisation and benefits of MWHs. Objective To explore providers’ and clients’ perspectives on facilitators and barriers to the use of MWH in rural Rwanda. Methods We conducted a qualitative study to explore health providers’ and clients’ perspectives on facilitators and barriers to the use of MWH in Rwanda, between December 2020 and January 2021. We used key informant interviews and focus group discussions to collect data. Data were analysed using NVivo qualitative analysis software version 11. Results Facilitators included perceptions that the MWH offered either a peaceful and home-like environment, good-quality services, or timely obstetric services, and was associated with good maternal and neonatal outcomes. Barriers included limited awareness of the MWH among pregnant women, fear of health providers to operate the MWH at full capacity, women’s lack of autonomy, uncertainty over funding for the MWH, and perceived high user fees. Conclusion The Ruli MWH offers a peaceful environment for pregnant women while providing quality and timely obstetric care, resulting in positive maternal and neonatal outcomes for women. However, its existence and benefits are not widely known, and its use is limited due to inadequate resources. There is a need for increased awareness of the MWH among healthcare providers and the community, and lessons from this MWH could inform the scale up of MWHs in Rwanda.

The midwives service scheme: a qualitative comparison of contextual determinants of the performance of two states in central Nigeria.

BackgroundThe federal government of Nigeria started the Midwives Service Scheme in 2009 to address the scarcity of skilled health workers in rural communities by temporarily redistributing midwives from urban to rural communities. The scheme was designed as a collaboration among federal, state and local governments. Six years on, this study examines the contextual factors that account for the differences in performance of the scheme in Benue and Kogi, two contiguous states in central Nigeria.MethodsWe obtained qualitative data through 14 in-depth interviews and 2 focus group discussions: 14 government officials at the federal, state and local government levels were interviewed to explore their perceptions on the design, implementation and sustainability of the Midwives Service Scheme. In addition, mothers in rural communities participated in 2 focus group discussions (one in each state) to elicit their views on Midwives Service Scheme services. The qualitative data were analysed for themes.ResultsThe inability of the federal government to substantially influence the health care agenda of sub-national governments was a significant impediment to the achievement of the objectives of the Midwives Service Scheme. Participants identified differences in government prioritisation of primary health care between Benue and Kogi as relevant to maternal and child health outcomes in those states: Kogi was far more supportive of the Midwives Service Scheme and primary health care more broadly. High user fees in Benue was a significant barrier to the uptake of available maternal and child health services.ConclusionDifferential levels of political support and prioritisation, alongside financial barriers, contribute substantially to the uptake of maternal and child health services. For collaborative health sector strategies to gain sufficient traction, where federating units determine their health care priorities, they must be accompanied by strong and enforceable commitment by sub-national governments.

Data, Data Everywhere, but Access Remains a Big Issue for Researchers: A Review of Access Policies for Publicly-Funded Patient-Level Health Care Data in the United States.

Introduction:High quality research regarding treatment effectiveness, quality, and value is critical for improving the U.S. health care system. Recognition of this has led federal and state officials to better leverage existing data sources such as medical claims and survey data, but access must be balanced with privacy concerns.Methods:We reviewed and catalogued data access policies for a selection of publicly-funded federal and state datasets to investigate how such policies may be promoting or limiting research activities.Results:We found significant variation in data access policies across federal agencies and across state agencies, including variation for multiple datasets available from the same agency. We also observed numerous indirect hurdles to use of data, including complex data use application procedures, high user fees, and prolonged wait times for data delivery.Conclusions:Policy makers and data owners should consider making changes to data access policies to maximize the utility and availability of these valuable resources.

A practical tool for modeling biospecimen user fees.

The question of how best to attribute the unit costs of the annotated biospecimen product that is provided to a research user is a common issue for many biobanks. Some of the factors influencing user fees are capital and operating costs, internal and external demand and market competition, and moral standards that dictate that fees must have an ethical basis. It is therefore important to establish a transparent and accurate costing tool that can be utilized by biobanks and aid them in establishing biospecimen user fees. To address this issue, we built a biospecimen user fee calculator tool, accessible online at www.biobanking.org . The tool was built to allow input of: i) annual operating and capital costs; ii) costs categorized by the major core biobanking operations; iii) specimen products requested by a biobank user; and iv) services provided by the biobank beyond core operations (e.g., histology, tissue micro-array); as well as v) several user defined variables to allow the calculator to be adapted to different biobank operational designs. To establish default values for variables within the calculator, we first surveyed the members of the Canadian Tumour Repository Network (CTRNet) management committee. We then enrolled four different participants from CTRNet biobanks to test the hypothesis that the calculator tool could change approaches to user fees. Participants were first asked to estimate user fee pricing for three hypothetical user scenarios based on their biobanking experience (estimated pricing) and then to calculate fees for the same scenarios using the calculator tool (calculated pricing). Results demonstrated significant variation in estimated pricing that was reduced by calculated pricing, and that higher user fees are consistently derived when using the calculator. We conclude that adoption of this online calculator for user fee determination is an important first step towards harmonization and realistic user fees.

IRRIGATION WATER PRICING AND COST RECUPERATION FOR SUSTAINABILITY OF IRRIGATION PROJECTS IN NYANYADZI, ZIMBABWE

Water pricing and recuperation of the costs of irrigation investment have been litigious issues for many decades in the dry area of Nyanyadzi because the community view irrigation as a development expenditure, financed by donors and the government for backward areas through lowering of food prices and reduction of tariffs. The soaring charges for irrigation water are questioned, as well as, the diminutive percentage of farmers who fundamentally recompense the charges. The failure to institute clear cost recuperation and water pricing methods has threatened the viability and sustainability of irrigation projects in the study area. The study used both qualitative and quantitative research methodologies. The study revealed that where the economy is usually subsidized, convalesce the cost of water delivery is much more complicated and difficult. In the case of establishing user fees, these should be estimated as a percentage of the traditional user's capability for derived from irrigation benefits (the net increase in farmers' income as a result of irrigation). Nyanyadzi has an opportunity in irrigation led development, if stakeholders address critical challenges in the planning, design, water delivery and maintenance of its irrigation systems. Since Nyanyadzi faces severe budgetary difficulties in financing irrigation projects, it is obligatory to consider the foundation on which irrigation projects operate and impose the principle of self sustaining. Sustainable methods of irrigation evaluation and collection of fees must be considered in light of Nyanyadzi's economic and technical environment. The research noted that water use efficiency is required in order to maximize the benefits farmers derive from the irrigation projects and extraordinarily high user fees should be avoided in the project development stages, where the payment capability is much less at the beginning than at the maturity stages of irrigation projects.

Looking at the Russian health care system: through the eyes of patients with diabetes and their physicians

Aims People with diabetes are well placed to evaluate and to assess the performance of health systems. We take the perspective of people living with diabetes and those caring for them to gain insights into how the contemporary Russian health system works for them. Methods We conducted 15 semi-structured interviews with patients with diabetes and physicians in rural and urban settings, in public and private sectors. Interviewees were identified using snowball sampling. Results Patients worried about high and rising costs of care, while physicians noted concerns about lack of time to treat patients adequately. Although all specifically diabetes-related services are free of charge, patients requiring urgent surgery often face high user fees, either to bypass waiting lists in state facilities or to be treated immediately in a private institution. These ‘hidden’, out-of-pocket payments impact adversely on equity and act as a barrier to timely care. Conclusions Although reform of health services in Russia has led to improvements in quality of care for diabetes, many gaps remain, particularly for management of complications. This paper provides further evidence of how people with diabetes can shed light on the reality, as opposed to the rhetoric of health system reform, especially in middle-income countries.

Pricing-out effect from possible user-fee policies under Taiwan’s National Health Insurance

This article simulates the pricing-out effect due to various user-fee policies under Taiwan’s National Health Insurance. Our simulation results indicate that the lower income group is more likely to be priced out of the healthcare system than the higher income group. On average, pricing-out effects are 0.04, 0.21, 0.52 and 0.73% of total beneficiaries with respect to the new co-payment policy, the catastrophic insurance policy, the under insurance policy, and the case of no National Health Insurance, respectively. We caution that a reduction of healthcare utilization due to higher user fees could result in some patients being left behind without professional care because the pricing-out effects could be higher than the substitution effects diverting demand to other professional care alternatives.

Private sector provision and financing of AIDS treatment in Africa: Current developments

Despite the rapid expansion of public sector highly active antiretroviral (ARV) treatment programs, the private sector continues to be an important source of services and financing for AIDS treatment in Africa. This article reviews currently available information on private sector initiatives, including recent innovations. Private sector providers continue to offer ARV treatment, although adherence problems resulting from high user fees indicate the need for employer, donor, or insurance support. Employer clinics have reported impressive results in patient recruitment and survival. Health insurers are removing AIDS exclusions and expanding AIDS coverage, in some cases with targeted lower cost policies. Public- or donor-funded ARVs have been used to leverage the expansion of populations treated at employer clinics, and attempts are underway to contract for private sector services using public and donor funds. With both funds and clinical resources stretched to meet AIDS treatment goals in countries with a high prevalence of HIV, further efforts are indicated to leverage private sector resources as part of a national treatment plan.

The Permanent Transition In Africa

Abstract: The negative impact of hegemonic neoliberal policies on women has been well documented globally, but it is more intense and absolute in Sub-Saharan Africa because of specific economic characteristics frequently found there. With few exceptions, its national economies are small, with especially small industrial sectors. Their orientation towards primary product exports, dominated by men locally and globally, remains strong from colonial rule, ended less than 50 years ago. Recent structural adjustment programs (SAPs) have only reinforced this imbalance. The credit and demand restraints associated with SAPs cause deep economic hardship among women and the poor, as consumers and workers. Capital shortage and unreliable infrastructure inhibit the anticipated supply response from local entrepreneurs or foreign investment. Widespread layoffs, higher user fees and government cutbacks in already minimal public services increase poor women's domestic drudgery, health care burdens and income pressures, while reducing their employment prospects and earnings.

Public Perceptions Of Private Health Care In Socialist China

We present the findings of a United Nations Development Programme-World Health Organization study commissioned by China's Ministry of Health on use of public and private ambulatory care services in three Chinese provinces. We found much unmet medical need (16 percent), attributed mainly to the perceived high cost of care. Seventy-one percent had no health insurance (90 percent in rural and 51 percent in urban areas). For 33 percent, the last consultation was with a private practitioner. Widespread dissatisfaction with public providers (mainly high user fees and poor staff attitudes) is driving patients to seek cheaper but lower-quality care from poorly regulated private providers.

Scamming the Poor

Abstract Because of the difficulty in securing traditional forms of credit, the poor are often driven into the fringe economy for check cashing, bill paying and short-term loans. These services involve high user fees and exorbitant interest rates that rival or even exceed those for illegal loan sharking. Fringe lending businesses function as a legal and virtually unregulated form of predatory loan-sharking. They neither offer nor promote savings-based financial products that build assets and increase household wealth. The predictable outcome is the depletion of the income and assets of low-income families and communities. Because many poor clients are vulnerable to fringe market lenders, social workers need to understand this market to better assist the poor in finding and developing alternative forms of borrowing. This article will explore the rapidly growing fringe economy and examine strategies to help curb the drain of income and assets from low-income communities.

Commuter-Based Carsharing: Market Niche Potential

The automobile accounts for more than 95 percent of all person miles traveled in the United States, whereas transit accounts for less than 3 percent of all trips. Between the private automobile and traditional transit, niche markets exist for other transportation services, such as airport and transit feeder shuttles and carsharing. Commuter-based carsharing, by which individuals share a fleet of vehicles linked to transit, could potentially fill and expand one such niche; complement existing services, mainly transit and feeder shuttles; and develop into a viable transportation alternative. A brief overview is presented of transit feeder services, particularly in Northern California. The CarLink I field test is described—a commuter-based carsharing model developed and tested in the San Francisco Bay Area in 1999. Key behavioral findings are highlighted. Recommendations are made for strengthening the viability of this innovative service, mainly on the basis of experience from the CarLink I field test. Empirical evidence suggests that CarLink could be sustainable if certain conditions exist: strong cooperation with local businesses and transit is established; parking limitations and congestion are prevalent; system feasibility is demonstrated; incentives are used (e.g., preferred parking and transit pass subsidies); higher user fees are generated; and technology and management costs are lowered. Further, CarLink’s long-term potential and viability could be strengthened by a combination of approaches, including cost reduction strategies, policy incentives, linkages to other complementary services (e.g., ridesharing), and local program support (e.g., demonstration grants).

Women and market forces

There was much evidence of the reproductive-technology revolution on display this year (Wilmut), particularly at the world congress of the International Federation of Gynaecology and Obstetrics in Copenhagen, Denmark, (Seppfilfi and the Lancet supplement on women's health). But the influence of market forces on obstetrics and gynaecology may be of greater relevance to women's health. This is illustrated by how such forces operate in subSaharan Africa and a Nordic country. In Africa, the market-forces concept was part of the macroeconomic programme introduced in the mid-1980s to cure the region's mounting economic ills. The desired result is yet to be achieved; instead, maternal health is being dealt a deadly blow--as fresh insights into the issues involved indicate (Harrison). The World Bank reckons that basic primary health care, including reproductive health care, costs US$12 per person per year. Most snb-Saharan African governments, overburdened by high indebtedness, allocate only US$2-3 per person per year. High user fees are charged to raise the extra money the hospitals need: these drive most people to selftreatment, quackery, and harmful traditional medicine. Consequently, more women are admitted with life-threatening emergencies because they have not had proper care: women cannot pay for care, nevertheless they die in the hands of good doctors. Fetal loss is huge, and the Trends in invasive cervical babies who survive, stunted by deprivation, go on to produce their own damaged babies. Meanwhile, failure adequately to invest in education and in health sustains Africa's high prevalence of negative reproductive characteristics: these include early marriage, early teenage pregnancy, low contraceptive use, high parity, and the many maternal deaths caused by illegal abortions. Poverty and deprivation force women into prostitution, which is an important factor in the rapid spread of heterosexual HIV/AIDS. In the Nordic countries the position is entirely different. The accommodation of the public sector services to the concept of the market economy has revolutionised the treatment of gynaecological disorders. Ectopic pregnancies

Maternal Mortality in Nigeria: The Real Issues

In Nigeria maternal mortality is estimated to be 1000/100000 births and rising. Nigeria is one of the 29 countries in sub-Saharan Africa that are among the 47 poorest countries in the world. Since 1950 the gulf between the richest and poorest countries in the world has increased from 8-fold to 30-fold. The impact of Nigerias poverty on maternal mortality can be seen by the fact that for Nigeria a 400-fold increase in maternal death accompanies a 66-fold disadvantage in gross national produce per capita as compared to Singapore (the countries were comparable in the 1960s). Most hospital maternal deaths in Nigeria occur after emergency hospitalization of women who received no prenatal care and/or were neglected in labor and during the postpartum period. Most of these women suffer simultaneous morbidities which increase risk to themselves and their babies. Structural adjustment programs have contributed to the decline in maternal health by instituting policies that promote inequities fail to control debt and lead to declining school enrollments and dismantling of social welfare programs. High user fees have discouraged at-risk women from seeking care and the number of women at risk is increased by early marriage low contraceptive prevalence high fertility and unsafe illegal abortions. Examples exist of poor countries where maternal mortality has been reduced drastically by widespread literacy and contraceptive usage and equity in health care. Nigeria has the capacity of achieving equally good results by establishing proper referral systems and exempting pregnant women from user fees. What is required is determined leadership and a focus on emergency obstetric treatment as well as efforts to reduce the occurrence of such emergencies.

Videoconferencing On-Line: Enhancing Communication over the Internet

Videoconferencing technology allows geographically disparate parties to see and hear one anotheracross campus or around the globeusually through satellite or telephone communication systems. It is typically an expensive undertaking involving costly equipment, high user fees, and elaborate infrastructure, often including a dedicated videoconferencing room. These costs and the required preparations for a videoconference have limited the number of potential

Access and payment for health care: the poor of Northern Vietnam.

In common with many developing countries, Vietnam has begun to introduce user fees at community and district level. This is part response to the transformation of the economy, economic recession, and the growing acceptability of alternative forms of health finance. This article examines the impact of these charges on the rural poor. Results from a 1995 survey in North Vietnam suggest that the poor generally delay treatment, make less use of government health facilities, and pay more for each episode of illness than the rich. There is evidence that the poor are forced to reduce consumption of essential goods or to borrow to meet these charges. A significant minority are deterred from using facilities. The current system of exemptions fails to provide adequate protection to the poor and a completely new system is required. The results suggest that it is the poor in poorer communes that are most affected by high user fees and it is to these areas that any assistance from government or donors should be targeted.

The Influence of Information on Users' Attitudes Toward Campground User Fees

Public agencies that provide outdoor recreational facilities are seeking additional sources of funding to operate existing facilities and to provide new recreational opportunities. Higher user fees...

The effects of non-optimal pricing and investment policies for transportation facilities

A simulation model was used to show the impacts of non-optimal pricing and investment timing policies for a major airport and an urban expressway. It was found that: the losses of economic surplus due to non-optimal pricing and investment policies were relatively small (less than 1% of the net present value of economic surplus for optimal pricing and investment), that marginal cost pricing covers the capital cost of all but the first increment of capacity, that higher user fees will permit the facilities to break even with relatively small losses of economic surplus, that marginal cost pricing has some effect relative to existing pricing policies in delaying the dates new capacity is required and achieving better capacity utilization, and that the shape of the cost function has a substantial impact on the amount of capacity required.