User Fee Exemption Policy Research Articles

User fee exemption policies in Mali: sustainability jeopardized by the malfunctioning of the health system.

In Mali, where rates of attendance at healthcare facilities remain far below what is needed, three user fee exemption policies were instituted to promote access to care. These related to HIV/AIDS treatment, as of 2004, caesarean sections, since 2005, and treatment of malaria in children under five and pregnant women, since 2007. Our qualitative study compared these three policies, looking at their implementation provisions, functioning and outcomes. In each healthcare facility, we analysed documentation and carried out three months of on-site observations. We also conducted a total of 254 formal and informal interviews with health personnel and patients.While these exemptions substantially improved users' access to care, their implementation revealed deep dysfunctions in the health system that undermined them all, regardless of the policy studied. These policies provoked resistance among health professionals that manifested in their practices and revealed, in particular, the profit-generation logic within which they operate today. These dysfunctions reflect the State's incapacity to exercise its regulatory role and to establish policies that are aligned with the way the health system really works.

Diagnosis of a public policy: an introduction to user fee exemptions for healthcare in the Sahel.

During the last ten years, Burkina Faso, Mali and Niger have opted for selective user fee exemption policies, while remaining within the general framework of cost recovery. But they have each developed their own particular institutional mechanisms, different from those of their neighbour. This was the topic of a comparative research program combining both quantitative and qualitative surveys over a four-year period. This special issue presents papers setting exemption policies in the wider context of public policy and the day-to-day functioning of health systems (part 1); presenting overarching case studies (part 2); and reflecting on our methodological approach (part 3).User fee exemption policies were introduced in Burkina Faso, Mali and Niger during the first decade of this century. They cover several sector-based measures ('free healthcare' in everyday language), and sometimes come on top of high levels of subsidies which enabled significant reductions in the cost of certain drugs and treatments.From the late 1980s, these three countries were - and still are - subject to a comprehensive system of cost recovery at the point of delivery (a policy introduced following the Bamako Initiative), or, to be more precise, a system of partial payment of drugs and services by the user. Only a small proportion of the costs are actually recovered as the amounts charged to the users do not take salaries, investments or recurrent costs, which are all paid by the state, into account, and represent only a small percentage of the overall health budget (an order of magnitude of five percent is often cited at state level [1,2]. Nevertheless, the sums recovered by health centres enabled them to buy drugs and cover certain local expenses.However, for public health reasons, cost recovery has always been subject to a variety of sector-based exceptions, determined by the nature of the disease or intervention involved. For example, mass immunization (National Immunization Days) and routine vaccinations as part of the Extended Programme of Immunization (EPI), treatment relating to tuberculosis, leprosy, noma and Guinea worm, and measures for the prevention of epidemics all remained free of charge for users. The Bamako Initiative also made provision for a system that waived payment for patients who were too poor to pay for their treatment, however this system has never really been implemented (with regard to Burkina Faso, cf. [3]; for other countries in the region, see [4]).This exclusion of the most vulnerable and the low health indicators in Africa, which are jeopardizing the achievement of the Millennium Development Goals (MDGs), explain the many criticisms of cost recovery that have mounted up within the NGOs, the research community and international organizations since the 1990s (cf. Ridde, this issue). This growing pressure for the abolition of the financial barriers to healthcare is clearly positioned within the progressive trend towards universal coverage. An international consensus has set itself the goal of ensuring that, by 2030, all populations, regardless of earnings, geographical location and gender, benefit from the coverage of 80% of basic health services, and 100% protection against the financial risks associated with direct payment [5].This context explains why - over and above the three countries considered here and at around the same time - sector-based exemption policies were developed and implemented in a number of countries in Africa from the early years of this century [6].

Analysis of agency relationships in the design and implementation process of the equity fund in Madagascar

BackgroundThere are large gaps in the literature relating to the implementation of user fee policy and fee exemption measures for the poor, particularly on how such schemes are implemented and why many have not produced expected outcomes. In October 2003, Madagascar instituted a user fee exemption policy which established “equity funds” at public health centres, and used medicine sales revenue to subsidise the cost of medicine for the poor. This study examines the policy design and implementation process of the equity fund in Madagascar in an attempt to explore factors influencing the poor equity outcomes of the scheme.MethodsThis study applied an agency-incentive framework to investigate the equity fund policy design and implementation practices. It analysed agency relationships established during implementation; examined incentive structures given to the agency relationships in the policy design; and considered how incentive structures were shaped and how agents responded in practice. The study employed a case-study approach with in-depth analysis of three equity fund cases in Madagascar’s Boeny region.ResultsPolicy design problems, triggering implementation problems, caused poor equity performance. These problems were compounded by the re-direction of policy objectives by health administrators and strong involvement of the administrators in the implementation of policy. The source of the policy design and implementation failure was identified as a set of principal-agent problems concerning: monitoring mechanisms; facility-based fund management; and the nature and level of community participation. These factors all contributed to the financial performance of the fund receiving greater attention than its ability to financially protect the poor.ConclusionThe ability of exemption policies to protect the poor from user fees can be found in the details of the policy design and implementation; and implications of the policy design and implementation in a specific context determine whether a policy can realise its objectives. The equity fund experience in Madagascar, which illustrates the challenges of beneficiary identification, casts doubts on the application of the ‘targeting’ approach in health financing and raises issues to be considered in universal health policy formulation. The agency framework provides a useful lens through which to examine policy process issues.

Inequities in accessibility to and utilisation of maternal health services in Ghana after user-fee exemption: a descriptive study.

IntroductionInequities in accessibility to, and utilisation of maternal healthcare services impede progress towards attainment of the maternal health-related Millennium Development Goals. The objective of this study is to examine the extent to which maternal health services are utilised in Ghana, and whether inequities in accessibility to and utilization of services have been eliminated following the implementation of a user-fee exemption policy, that aims to reduce financial barriers to access, reduce inequities in access, and improve access to and use of birthing services.MethodsWe analyzed data from the 2007 Ghana Maternal Health Survey for inequities in access to and utilization of maternal health services. In measuring the inequities, frequency tables and cross-tabulations were used to compare rates of service utilization by region, residence and selected socio-demographic variables.ResultsFindings show marginal increases in accessibility to and utilisation of skilled antenatal, delivery and postnatal care services following the policy implementation (2003–2007). However, large gradients of inequities exist between geographic regions, urban and rural areas, and different socio-demographic, religious and ethnic groupings. More urban women (40%) than rural, 53% more women in the highest wealth quintile than women in the lowest, 38% more women in the best performing region (Central Region) than the worst (Upper East Region), and 48% more women with at least secondary education than those with no formal education, accessed and used all components of skilled maternal health services in the five years preceding the survey. Our findings raise questions about the potential equity and distributional benefits of Ghana’s user-fee exemption policy, and the role of non-financial barriers or considerations.ConclusionExempting user-fees for maternal health services is a promising policy option for improving access to maternal health care, but might be insufficient on its own to secure equitable access to maternal health services in Ghana. Ensuring equity in access will require moving beyond user-fee exemption to addressing wider issues of supply and demand factors and the social determinants of health, including redistributing healthcare resources and services, and redressing the positional vulnerability of women in their communities.

No effect of user fee exemption on perceived quality of delivery care in Burkina Faso: a case-control study

BackgroundAlthough many developing countries have developed user fee exemption policies to move towards universal health coverage as a priority, very few studies have attempted to measure the quality of care. The present paper aims at assessing whether women’s satisfaction with delivery care is maintained with a total fee exemption in Burkina Faso.MethodsA quasi-experimental design with both intervention and control groups was carried out. Six health centres were selected in rural health districts with limited resources. In the intervention group, delivery care is free of charge at health centres while in the control district women have to pay 900 West African CFA francs (U$2). A total of 870 women who delivered at the health centre were interviewed at home after their visit over a 60-day range. A series of principal component analyses (PCA) were carried out to identify the dimension of patients’ satisfaction.ResultsWomen’s satisfaction loaded satisfactorily on a three-dimension principal component analysis (PCA): 1-provider-patient interaction; 2-nursing care services; 3-environment. Women in both the intervention and control groups were satisfied or very satisfied in 90% of cases (in 31 of 34 items). For each dimension, average satisfaction was similar between the two groups, even after controlling for socio-demographic factors (p = 0.436, p = 0.506, p = 0.310, respectively). The effects of total fee exemption on satisfaction were similar for any women without reinforcing inequalities between very poor and wealthy women (p ≥ 0.05). Although the wealthiest women were more dissatisfied with the delivery environment (p = 0.017), the poorest were more highly satisfied with nursing care services (p = 0.009).ConclusionContrary to our expectations, total fee exemption at the point of service did not seem to have a negative impact on quality of care, and women’s perceptions remained very positive. This paper shows that the policy of completely abolishing user fees with organized implementation is certainly a way for developing countries to engage in universal coverage while maintaining the quality of care.

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.

Out‐of‐pocket costs for paediatric admissions in district hospitals in Kenya

ObjectiveTo describe out-of-pocket costs of inpatient care for children under 5 years of age in district hospitals in Kenya.MethodsA total of 256 caretakers of admitted children were interviewed in 2-week surveys conducted in eight hospitals in four provinces in Kenya. Caretakers were asked to report care seeking behaviour and expenditure related to accessing inpatient care. Family socio-economic status was assessed through reported expenditure in the previous month.ResultsSeventy eight percent of caretakers were required to pay user charges to access inpatient care for children. User charges (mean, US$ 8.1; 95% CI, 6.4–9.7) were 59% of total out-of-pocket costs, while transport costs (mean, US$ 4.9; 95% CI, 3.9–6.0) and medicine costs (mean, US$ 0.7; 95% CI, 0.5–1.0) were 36% and 5%, respectively. The mean total out-of-pocket cost per paediatric admission was US$ 14.1 (95% CI, 11.9–16.2). Out-of-pocket expenditures on health were catastrophic for 25.4% (95% CI, 18.4–33.3) of caretakers interviewed. Out-of-pocket expenditures were regressive, with a greater burden being experienced by households with lower socio-economic status.ConclusionDespite a policy of user fee exemption for children under 5 years of age in Kenya, our findings show that high unofficial user fees are still charged in district hospitals. Financing mechanisms that will offer financial risk protection to children seeking care need to be developed to remove barriers to child survival.

A literature review of the disruptive effects of user fee exemption policies on health systems.

BackgroundSeveral low- and middle-income countries have exempted patients from user fees in certain categories of population or of services. These exemptions are very effective in lifting part of the financial barrier to access to services, but they have been organized within unstable health systems where there are sometimes numerous dysfunctions. The objective of this article is to bring to light the disruptions triggered by exemption policies in health systems of low- and middle-income countries.MethodsScoping review of 23 scientific articles. The data were synthesized according to the six essential functions of health systems.ResultsThe disruptions included specifically: 1) immediate and significant increases in service utilization; 2) perceived heavier workloads for health workers, feelings of being exploited and overworked, and decline in morale; 3) lack of information about free services provided and their reimbursement; 4) unavailability of drugs and delays in the distribution of consumables; 5) unpredictable and insufficient funding, revenue losses for health centres, reimbursement delays; 6) the multiplicity of actors and the difficulty of identifying who is responsible (‘no blame’ game), and deficiencies in planning and communication.ConclusionsThese disruptive elements give us an idea of what is to be expected if exemption policies do not put in place all the required conditions in terms of preparation, planning and complementary measures. There is a lack of knowledge on the effects of exemptions on all the functions of health systems because so few studies have been carried out from this perspective.

User fee exemptions and equity in access to caesarean sections: an analysis of patient survey data in Mali

IntroductionLittle rigorous evidence exists on how health service utilization varies across socioeconomic groups after a user fee exemption policy has been implemented, and the evidence that does exist is mixed. In this paper, we estimate the distribution of caesarean section deliveries across socioeconomic groups following Mali’s implementation of a fee exemption policy for caesareans in 2005.MethodsWe conducted a patient survey in 2010 to collect socioeconomic data from 2,477 women who had caesareans in a representative sample of 25 facilities across all regions of Mali. We used these data along with data from the most recent Demographic and Health Survey to construct a wealth index and classify women into population-based wealth groupings. We compared the wealth distribution of women delivering via caesarean section to that of a nationally representative sample of women giving birth.ResultsWe found that wealthier women make up a disproportionate share of those having free caesareans, five years after implementation of the fee exemption policy. Women in the richest two quintiles accounted for 58 percent of all caesareans, while women in the poorest two quintiles accounted for 27 percent of all caesareans. Fewer women in the poorest two-fifths of the population are receiving caesareans than what we would expect given their share in the population of women giving birth.ConclusionsWhile fee exemptions remove important financial barriers to accessing priority maternal health services, they are insufficient to ensure equal access among wealth groups.

Effect of delivery care user fee exemption policy on institutional maternal deaths in the central and volta regions of ghana.

To improve access to skilled attendance at delivery and thereby reduce maternal mortality, the Government of Ghana introduced a policy exempting all women attending health facilities from paying delivery care fees. To examine the effect of the exemption policy on delivery-related maternal mortality. Maternal deaths in 9 and 12 hospitals in the Central Region (CR) and the Volta Region (VR) respectively were analysed. The study covered a period of 11 and 12 months before and after the introduction of the policy between 2004 and 2006. Maternal deaths were identified by screening registers and clinical notes of all deaths in women aged 15-49 years in all units of the hospitals. These deaths were further screened for those related to delivery. The total births in the study period were also obtained in order to calculate maternal mortality ratios (MMR). A total of 1220 (78.8%) clinical notes of 1549 registered female deaths were retrieved. A total of 334 (21.6%) maternal deaths were identified. The delivery-related MMR decreased from 445 to 381 per 100,000 total births in the CR and from 648 to 391 per 100,000 total births in the VR following the implementation of the policy. The changes in the 2 regions were not statistically significant (p=0.458) and (p=0.052) respectively. No significant changes in mean age of delivery-related deaths, duration of admission and causes of deaths before and after the policy in both regions. The delivery-related institutional maternal mortality did not appear to have been significantly affected after about one year of implementation of the policy.

Implementing Intermittent Preventive Treatment for Malaria in Pregnancy: Review of Prospects, Achievements, Challenges and Agenda for Research.

INTRODUCTION: Implementing Intermittent Preventive Treatment for malaria in Pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) through antenatal care (ANC) clinics is recommended for malaria endemic countries. Vast biomedical literature on malaria prevention focuses more on the epidemiological and cost-effectiveness analyses of the randomised controlled trials carried out in selected geographical settings. Such studies fail to elucidate the economic, psychosocial, managerial, organization and other contextual systemic factors influencing the operational effectiveness, compliance and coverage of the recommended interventions. OBJECTIVE: To review literature on policy advances, achievements, constraints and challenges to malaria IPTp implementation, emphasising on its operational feasibility in the context of health-care financing, provision and uptake, resource constraints and psychosocial factors in Africa. RESULTS: The importance of IPTp in preventing unnecessary anaemia, morbidity and mortality in pregnancy and improving childbirth outcomes is highly acknowledged, although the following factors appear to be the main constraints to IPTp service delivery and uptake: cost of accessing ANC; myths and other discriminatory socio-cultural values on pregnancy; target users, perceptions and attitudes towards SP, malaria, and quality of ANC; supply and cost of SP at health facilities; understaffing and demoralised staff; ambiguity and impracticability of user-fee exemption policy guidelines on essential ANC services; implementing IPTp, bednets, HIV and syphilis screening programmes in the same clinic settings; and reports on increasing parasite resistant to SP. However, the noted increase in the coverage of the delivery of IPTp doses in several countries justify that IPTp implementation is possible and better than not. CONCLUSION: IPTp for malaria is implemented in constrained conditions in Africa. This is a challenge for higher coverage of at least two doses and attainment of the Abuja targets. Yet, there are opportunities for addressing the existing challenges, and one of the useful options is the evaluation of the acceptability and viability of the existing intervention guidelines.

The Experience of Ghana in Implementing a User Fee Exemption Policy to Provide Free Delivery Care

In resource-poor countries, the high cost of user fees for deliveries limits access to skilled attendance, and contributes to maternal and neonatal mortality and the impoverishment of vulnerable households. A growing number of countries are experimenting with different approaches to tackling financial barriers to maternal health care. This paper describes an innovative scheme introduced in Ghana in 2003 to exempt all pregnant women from payments for delivery, in which public, mission and private providers could claim back lost user fee revenues, according to an agreed tariff. The paper presents part of the findings of an evaluation of the policy based on interviews with 65 key informants in the health system at national, regional, district and facility level, including policymakers, managers and providers. The exemption mechanism was well accepted and appropriate, but there were important problems with disbursing and sustaining the funding, and with budgeting and management. Staff workloads increased as more women attended, and levels of compensation for services and staff were important to the scheme’s acceptance. At the end of 2005, a national health insurance scheme, intended to include full maternal health care cover, was starting up in Ghana, and it was not yet clear how the exemptions scheme would fit into it.RésuméDans les pays pauvres, le montant élevé des contributions demandées aux patientes pour les accouchements limite l’accès à des soins de qualité, tout en contribuant à la mortalité maternelle et néonatale et à l’appauvrissement des ménages vulnérables. Un nombre croissant de pays expérimentent différentes méthodes pour lever les obstacles financiers aux soins de santé maternelle. Un projet novateur, introduit au Ghana en 2003, exonérait toutes les femmes enceintes du paiement des accouchements et prévoyait que les praticiens publics, privés et des missions pouvaient récupérer leurs honoraires perdus, conformément à un barème convenu. L’article présente une partie des conclusions d’une évaluation de cette politique, sur la base d’entretiens avec 65 informateurs clés dans le système de santé aux niveaux national, régional, des districts et des maternités, notamment des responsables politiques, des gestionnaires et des praticiens. Le mécanisme d’exonération a été bien accepté et était satisfaisant, mais il connaissait de graves problèmes de décaissement des fonds et de maintien du financement, ainsi que de budgétisation et de gestion. La charge de travail du personnel a augmenté car davantage de femmes ont demandé des soins, et les niveaux de compensation pour les services et le personnel étaient importants pour l’acceptation du projet. Fin 2005, un plan national d’assurance maladie, devant couvrir totalement les soins de santé maternelle, démarrait au Ghana et la manière dont le projet d’exonération s’y adapterait n’était pas encore claire.ResumenEn los países con pocos recursos, el alto costo de las tarifas por partos limita el acceso a asistencia calificada y contribuye a la mortalidad materna y neonatal y al empobrecimiento de hogares vulnerables. En un creciente número de países se está experimentando con diferentes estrategias para afrontar los obstáculos financieros a los servicios de salud materna. En este artículo se describe un plan innovador presentado en Ghana en 2003 para eximir a todas las mujeres embarazadas de pagos por parto, mediante el cual los prestadores de servicios públicos, misioneros y privados pueden reclamar ingresos perdidos de tarifas de usuarias, de acuerdo con una tarifa acordada. Se expone parte de los resultados de una evaluación de la política basada en entrevistas con 65 informantes clave (incluidos formuladores de políticas, administradores y prestadores de servicios) del sistema de salud a nivel nacional, regional, distrital y local. El mecanismo de exención fue bien aceptado y apropiado, pero hubo problemas importantes con el desembolso y sustento del financiamiento, así como con los presupuestos y la administración. El volumen de trabajo del personal aumentó a medida que se atendían más mujeres, y los niveles de remuneración por servicios y personal fueron esenciales para la aceptación del plan. A fines de 2005, se estaba iniciando en Ghana un plan nacional de seguro médico, con el objetivo de incluir cobertura completa de servicios de salud materna, pero aún no era claro cómo el plan de exenciones se integraría a éste.