User Fees For Health Services Research Articles

Does abolishing user fees for family planning increase contraception use? An impact evaluation of the national policy in Burkina Faso.

BackgroundUnmet needs for contraception constitute a major public health problem in sub-Saharan Africa. Several mechanisms have been tested to reduce the financial barrier and facilitate access to family planning services, with inconclusive results. Based on the positive impacts following the introduction of free health care for pregnant women, Burkina Faso decided to extend its national policy and abolished direct payment for family planning services. This study aims to evaluate the impact of this policy on contraceptive use and unmet needs for contraception among women of reproductive age (WRA) in Burkina Faso.MethodsThis study uses two different study designs to examine the impact of a user fee removal policy on contraceptive use across a panel of 1400 households randomly selected across eight health districts. Data were collected using a standardized socio-demographic questionnaire at three different time points during the pilot and scale-up phases of the fee abolition program. The questionnaire was administered six months after the launch of the pilot fee abolition program in four health districts. For the remaining four health districts, the survey was conducted one year prior to and six months after the implementation of the program in those areas. All WRA in the households were eligible to participate. A cross-sectional study design was used to determine the association between knowledge of the fee abolition policy among WRA and actual use of contraceptives by WRA six months after the policy’s implementation and across all eight districts. Additionally, a pre-post study with a non-randomized, reflexive control group was designed using repeated surveys in four health districts. Hierarchical logistic mixed effects models were adjusted for a set of time-variant individual variables; the impact was assessed by a difference-in-differences approach that compared pre-post changes in contraception use in women who knew about the new policy and those who did not.ResultsOf the 1471 WRA surveyed six months after the removal of user fees for family planning services, 56% were aware of the policy’s existence. Knowledge of the fee abolition policy was associated with a 46% increase probability of contraceptive use among WRA six months after the policy’s implementation. Among the subset of the participants who were surveyed twice (n = 507), 65% knew about the fee removal policy six months after its introduction and constitute the intervention group. Pre-post changes in contraceptive use differed significantly between the intervention (n = 327) and control groups (n = 180). Removing user fees for family planning led to an 86% (95% confidence interval (CI) = 0.49, 1.31) increase in the likelihood of using contraception. In the study area, the policy reduced the prevalence of unmet needs for contraception by 13 percentage points.ConclusionsRemoving user fees for family planning services is a promising strategy to increase access to, and reduce unmet needs for, contraception. A broader dissemination of the policy’s existence will likely increase its impact on the overall population.

Are user fees in health care always evil? Evidence from family planning, maternal, and child health services

The effect of introducing or increasing user fees for health services in low- and middle-income countries is controversial. While user fees are advocated as an effective means of generating revenue and enabling health service quality improvement, they constitute a financial barrier to access health services for the poorer. This paper contributes to the literature on the demand-side financing in health by providing evidence on the medium-term effects of introducing user fees on the utilisation of family planning, antenatal care, and delivery care services, women’s access to health care, and child health status in a middle-income country setting. Using a difference-in-differences identification strategy to establish causality, we find that the introduction of user fees in Egypt had no negative effect on the utilisation of family planning and delivery care services. Further, fees did not hinder women’s access to care and did not harm child health outcomes. Positive effects were even observed with respect to the utilisation of antenatal care services. Our findings are compatible with the hypothesis that the potential decrease in demand due to the user fee imposition might have been offset by an increased willingness to pay for a quality of health care that could be, at least partly, perceived as higher.

Removing user fees for health services: A multi-epistemological perspective on access inequities in Senegal

Plan Sésame (PS) is a user fee exemption policy launched in 2006 to provide free access to health services to Senegalese citizens aged 60 and over. Analysis of a large household survey evaluating PS echoes findings of other studies showing that user fee removal can be highly inequitable. 34 semi-structured interviews and 19 focus group discussions with people aged 60 and over were conducted in four regions in Senegal (Dakar, Diourbel, Matam and Tambacounda) over a period of six months during 2012. They were analysed to identify underlying causes of exclusion from/inclusion in PS and triangulated with the household survey. The results point to three steps at which exclusion occurs: (i) not being informed about PS; (ii) not perceiving a need to use health services under PS; and (iii) inability to access health services under PS, despite having the information and perceived need. We identify lay explanations for exclusion at these different steps. Some lay explanations point to social exclusion, defined as unequal power relations. For example, poor access to PS was seen to be caused by corruption, patronage, poverty, lack of social support, internalised discrimination and adverse incorporation. Other lay explanations do not point to social exclusion, for example: poor implementation; inadequate funding; high population demand; incompetent bureaucracy; and PS as a favour or moral obligation to friends or family. Within a critical realist paradigm, we interpret these lay explanations as empirical evidence for the presence of the following hidden underlying causal mechanisms: lacking capabilities; mobilisation of institutional bias; and social closure. However, social constructionist perspectives lead us to critique this paradigm by drawing attention to contested health, wellbeing and corruption discourses. These differences in interpretation lead to subsequent differential policy recommendations. This demonstrates the need for the adoption of a “multi-epistemological” perspective in studies of health inequity and social exclusion.

Free versus subsidised healthcare: options for fee exemptions, access to care for vulnerable groups and effects on the health system in Burkina Faso

BackgroundThe many forms of healthcare fee exemptions implemented in Burkina Faso since the 2000s have varied between total exemption (free) and cost subsidisation. This article examines both options, their contextual variations and the ways in which they affect access to healthcare for vulnerable people as well as the operation of the health system. This research is part of an interdisciplinary regional program on the elimination of user fees for health services in West Africa (Burkina Faso, Mali and Niger).MethodA conceptual framework and a chronological review of policy interventions are used as references to summarise the results of the three qualitative studies presented. Historical reference points are used to describe the emergence of healthcare fee exemption policies in Burkina Faso and the events that influenced their adoption. The joint analysis of opinions on options for fee exemption focuses on the different types of repercussions on access to healthcare and the operation of the health system.ResultsIn conjunction with the twists and turns of the gradual development of a national health policy and in response to international recommendations, healthcare fee exemptions have evolved since colonisation. The limitations of the changes introduced with cost recovery and the barriers to healthcare access for the poorest people led to the adoption of the current sectorial fee exemptions. The results provide information on the reasons for the changes that have occurred over time. The nuanced perspectives of different categories of people surveyed about fee exemption options show that, beyond the perceived effects on healthcare access and the health system, the issue is one of more equitable governance.ConclusionsIn principle, the fee exemption measures are intended to provide improved healthcare access for vulnerable groups. In practice, the negative effects on the operation of the health system advocate for reforms to harmonise the changes to multifaceted fee exemptions and the actual needs to promote effectiveness and sustainability.

Does Abolishing User Fees Lead to Improved Health Status? Evidence from Post-Apartheid South Africa

Whether user fees for health services should be charged or abolished for the poor has recently been debated. This study examines the impact on child health status of removing user fees in South Africa. Our main innovation is to exploit plausibly exogenous variation in access to free health care, due to the fact that black Africans under apartheid could exercise little political power and residential choice. We find substantial improvements in weight-for-age z-scores among ex ante similar children. Falsification exercises confirm no preexisting trend in the pre-reform period or no treatment effect among noneligible children in the post-reform period. (JEL H51, I12, I18, I38, J13, O15, O17)

David Hercot, Meesen Bruno, Ridde Valery and Lucy Gilson. Removing user fees for health services in low-income countries: A multi-country review framework for assessing the process of policy change. Health Policy and Planning 2011, 26(2)

<b>David Hercot, Meesen Bruno, Ridde Valery and Lucy Gilson</b>. Removing user fees for health services in low-income countries: A multi-country review framework for assessing the process of policy change. <i>Health Policy and Planning</i> 2011, 26(2)

Removing user fees for health services in low-income countries: a multi-country review framework for assessing the process of policy change

Several authors have stressed the fact that many policy reforms fail because of poor formulation or implementation. On the other hand, the health financing literature provides little guidance to policy makers in low-income countries on how to implement a health care financing reform in ways that enhance its chance of achieving policy objectives, even less so for a user fee removal reform. This paper presents the framework used for a multi-country review of the policy process of removing user fees in six sub-Saharan African countries. The review aimed at developing operational guidance for health managers involved in user fee removal reform. Drawing broadly on Walt and Gilson's 'health policy analysis triangle' (context-actor-process-content), we focused particularly on understanding the process of planning and implementing the reform led by central-level policy actors. Our core analytic strategy was the verification of a list of 'good practice hypotheses' that might be expected in a health financing policy reform against experience. This framework offers an approach for how to analyse health financing policy reform processes in low-income countries. It allows for an explicit and transparent review of multiple experiences against a set of clear hypotheses. This approach might be a step in the direction of research that supports better formulation and implementation of policies in resource-poor settings.

Women and children first: an appropriate first step towards universal coverage

There is a growing consensus that achieving universal health coverage is an appropriate, feasible and important goal for all nations. Under a rallying cry of “All for universal coverage”, Garrett et al. explain in a Lancet paper that attaining universal coverage will be vital if we are to reach health, poverty eradication and human rights goals.1

The impact of user fees on health service utilization in low- and middle-income countries: how strong is the evidence?

To assess the effects of user charges on the uptake of health services in low- and middle-income countries. A systematic search of 25 social science, economics and health literature databases and other sources was performed to identify and appraise studies on the effects of introducing, removing, increasing or reducing user charges on the uptake of various health services in low- and middle-income countries. Only experimental or quasi-experimental study designs were considered: cluster randomized controlled trials (C-RCT), controlled " before and after" (CBA) studies and interrupted time series (ITS) studies. Papers were assessed in which the effect of the intervention was measured in terms of changes in service utilization (including equity outcomes), household expenditure or health outcomes. Sixteen studies were included: five CBA, two C-RCT and nine ITS. Only studies reporting effects on health service utilization, sometimes across socioeconomic groups, were identified. Removing or reducing user fees was found to increase the utilization of curative services and perhaps preventive services as well, but may have negatively impacted service quality. Introducing or increasing fees reduced the utilization of some curative services, although quality improvements may have helped maintain utilization in some cases. When fees were either introduced or removed, the impact was immediate and abrupt. Studies did not adequately show whether such an increase or reduction in utilization was sustained over the longer term. In addition, most of the studies were given low-quality ratings based on criteria adapted from those of the Cochrane Collaboration's Effective Practice and Organisation of Care group. There is a need for more high-quality research examining the effects of changes in user fees for health services in low- and middle-income countries.

Public Service Provision, User Fees, and Political Turmoil

Following an electoral dispute, the central highlands of the island of Madagascar were subjected to an economic blockade during the first half of 2002. After the blockade ended in June 2002, user fees for health services and school fees were progressively eliminated. This paper examines the provision of schooling and health services to rural areas of Madagascar before, during, and after the blockade. We find that public services were more resilient to the blockade than initially anticipated, but that health services were more affected than schools. The removal of user fees had a large significant effect on public services that is distinct from the end of the blockade and the increase in school book provision.

Public Service Provision, User Fees and Political Turmoil

Following an electoral dispute, the central highlands of the island of Madagascar were subjected to an economic blockade during the Þrst half of 2002. After the blockade ended in June 2002, user fees for health services and school fees were progressively eliminated. This paper examines the provision of schooling and health services to rural areas of Madagascar before, during, and after the blockade. We Þnd that public services were more resilient to the blockade than initially anticipated, but that health services were more affected than schools. The removal of user fees had a large signiÞcant effect on public services that is distinct from the end of the blockade and the increase in school book provision.

An assessment of the free health care provision system in Jimma town, Southwest Ethiopia

Background: Despite the fact that equity is the underlying principle of all major global health policies, difficulties have emerged in providing proper care for the poor with the introduction of user fees for health services. However, the criteria used to determine eligibility for free health services at public health facilities are either unclear or nonexistent in most sub-Saharan African countries.Objective: To assess the free health care delivery system and the extent to which strict criteria are followed in granting free health care services in Jimma town, southwest Ethiopia.Methods: A cross-sectional, exploratory study, employing both quantitative and qualitative study designs, was conducted from December 22–27, 2003.Results: Fifty-eight percent of the respondents were found to be patients exempted from fees on the day of interview. There exist no clearly stated criteria in the free health care provision system of Jimma town. The presence of leakage and under-coverage were 36.9% and 43.6% respectively. The occupation and income category of the respondents showed a statistically significant association with their service category at the public health facilities (p=0.000). Conclusion: The absence of clearly defined criteria for waiving user fees at public health facilities has made the free health care provision system difficult for both the providers and users. The system is also prone to the possibility of leakage and under-coverage. These findings imply the importance of a strict reconsideration of the exemption policy of the locality and the country with focus on efforts to produce clear criteria and guidelines in granting free health care. Ethiopian Journal of Health Development Vol. 19(3) 2005: 188-194

Social Protection and Health: Experiences in Uganda

There is an interesting and continuing debate on the nature and role of social protection in poverty reduction. Within the health sector, discussion has focussed on the drawbacks associated with fee exemption schemes and community‐based health insurance, with much less attention paid to the policy option of abolishing user fees. This paper reviews empirical evidence on the impact of the Government of Uganda's decision in 2001 to abolish user fees for health services. The paper finds that this policy intervention has had a significant positive impact on health‐seeking behaviour in Uganda and concludes that this policy measure can make an important contribution towards a more ‘promotional’ policy approach to social protection.

William Newbrander, David Collins and Lucy Gilson (eds), User fees for health services: guidelines for protecting the poor, Management Sciences for Health, King Printing Company: Boston, MA, USA, 2001, 60 pp., ISBN 0‐913723‐80‐0, $10.00

The International Journal of Health Planning and ManagementVolume 17, Issue 3 p. 283-285 Book Review William Newbrander, David Collins and Lucy Gilson (eds), User fees for health services: guidelines for protecting the poor, Management Sciences for Health, King Printing Company: Boston, MA, USA, 2001, 60 pp., ISBN 0-913723-80-0, $10.00 Sharif Ullah Khan, Corresponding Author Sharif Ullah Khan Deputy General Manager The Aga Khan Health Service Chitral Regional Office Mountain Inn Hotel NWFP Pakistan 17200The Aga Khan Health Service, Chitral Regional Office, Mountain Inn Hotel, NWFP, Pakistan 17200.Search for more papers by this author Sharif Ullah Khan, Corresponding Author Sharif Ullah Khan Deputy General Manager The Aga Khan Health Service Chitral Regional Office Mountain Inn Hotel NWFP Pakistan 17200The Aga Khan Health Service, Chitral Regional Office, Mountain Inn Hotel, NWFP, Pakistan 17200.Search for more papers by this author First published: 09 August 2002 https://doi.org/10.1002/hpm.676AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume17, Issue3July/September 2002Pages 283-285 RelatedInformation

Are people willing and able to pay for health services?

Following a nationwide increase in user fees for health services in Swaziland, this paper analyzes the effect of the fee increase on overall patient use of health services, on which types of services, curative vs preventive, were most affected, and on changes in utilization by higher paying and lower paying groups. Patient attendance data from a 71% sample of government and mission health facilities, suggests that the ‘people are willing and able to pay for health services’ assertion is not supported by the Swaziland case. Following the fee increase, average attendance decreased at government facilities by 32.4%, increased at mission facilities by 10.2%, leading to a combined decline of approx. 17%. Patient visits designed to protect against childhood diseases, BCG and DPT immunizations, or against dehydration in children, show average attendance decline of -16, -19, and -24%, respectively, while visits for musculoskeletal diseases, a less serious disease, declined 1.2%. The analysis also suggests that up to 34% of the overall decline in attendance was among patients who previously had paid the least for health care with part of this decline likely including fewer multiple visits.

The revenue generating potential of user fees in Kenyan government health facilities

This paper develops and implements a methodology for estimating the total revenue that would result from a system of user fees for health services provided by public facilities in a developing country. After setting out a set of principles based on efficiency, equity, and administrative goals upon which the user fees should be founded, a formula for estimating total revenue generated is presented which reflects six different factors affecting total revenues. These factors include reductions in demand due to imposing fees, exemption of selected services from any fees, forgiving fees from those unable to pay, and ‘leakage’ of revenue due to bribes, etc. Three specific fee structures are then examined for Kenya, and the total revenue to be generated is predicted. The revenue totals are large, on the order of 10–22% of the government's total recurrent health costs, suggesting that even modest user fees can make a significant contribution to public health costs.