Transcript PS 01-1 User fees Za.. - African Health Economics and Policy

User fee removal in Zambia:
What happened and what
was the impact?
A community focused study
AfHEA Conference
Accra, Ghana
!0th-12th March 2009
Mary Hadley, Lead Researcher
Collins Chansa, Ministry of Health
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Outline
 Objectives of the study
 Methods
 Implementation of policy
 Potential impact on health of population
-who attends?
-what they get?
-did they follow advice?
 Conclusion
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Objectives of qualitative component
Qualitative component of the User Fee
Evaluation was designed to:
1. Inform the wider research protocol
design
2. Assist with interpretation of the results
3. Explore in more depth areas that are not
easy to investigate using quantitative
methods
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Methods (1)
 A team of international
and national researchers
 Interviews n=(99),
discussions (n=23) and
observations (n=14)
 Key informants
 Users, non users, health
providers and community
volunteers and committee
members participated.
Discussion in a rural area with
Neighbourhood Health
Committee members
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Sites selected
Government
Faith-based/NGO Rural
Urban
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2
(3)
(4)
3 user fees
2 fees removed
Both fees removed
Health
Centres
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3
(5)
(13)
8 user fees
7 fees removed
1 user fees
1 fees removed
1 NGO
Total
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Hospitals
8 user fees,
4 fees removed ‘07
1 NGO
(8)
(17)
Total facilities n=25 Charging User Fees n=12 +1 (NGO)
User Fees Removed n=12
Facilities close to the border n=4
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Methods (2)
 Building on existing
information, three
broad questions were
used as the
framework for data
collection.
 Data generated was
triangulated for
validation purposes
and themes identified
 What do people do
when they get sick?
 What happens if they
go to a health facility?
 What do they do
when they get home?
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Implementation of policies
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Cost sharing policy
 Community involvement in setting and using
user fees was patchy
 Exemption policy for categories such as under
5s and over 65s and to some extent chronic
conditions and pregnant women were broadly
adhered to
 However, and importantly, exemption criteria for
‘those who are unable to afford’ was not
uniformly exercised leading to delays and
deaths in the communities.
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“…their niece got sick, she went to
the clinic and was asked to pay
K1,500 and then she informed
them that she didn’t have the
money, they sent her back, when
she got home, the father and
mother were away, when they just
returned home three days later
they found a copse.”
Interview- urban district-police
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“The other case, they didn't even take a
stab at going to the facility because
they knew that even if they went there,
they wouldn't be attended to because
they didn’t have the K1,500 for
treatment which the clinic asks for.....so
in the process of giving traditional
medicines, she died whilst at home”
interview- urban district (fees removed in 2007)-police
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Removal of user fee policy
 Not all eligible centres had removed
charges
 Fees for registration, investigations and
referrals continued to be charged.
Additional reasons for not accessing health
facilities Distance from the health facility,
lack of suitable clothing to attend the
clinics/ no soap, negative staff behaviour
towards patients, waiting times,
alternatives available
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“We have people in this community
that can still not afford to buy a
book for K500. some people are
aware that you do not pay user
fees at the clinic because they
have been removed. But they still
cannot afford to buy a book for
K500. Such people are there”.
Group discussion- rural clinic-users
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Impact of user fee removal
Three conditions…
1. People are sick and in
need of treatment in
order to fully recover or
to limit spread of a
disease
2. Comprehensive
treatment required to
meet these needs is
provided
3. People adhere to the
advice given (follow
through)
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1. People presenting at the
facilities following removal of user
fees included…
1. Those who did not use to come when fees
were charged (primarily those living near the
health facility and less poor)
2. People with diseases in the early stage
“We used to treat complications now we treat
diseases”
Interview-rural clinic- health worker
3. People not considered to be ‘sick’ by health
workers
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People who were not considered to
be ‘sick’ by health workers
Reports of …
 people coming with only a thorn prick, aching muscles
from working in the fields
 People just coming into the health centre because they
happen to be in the vicinity, collecting medicines to go
home
 People pretending to be ill, requesting medicines that do
not fit the signs and symptoms
 Mothers bringing all the children in at the same time with
vague symptoms and no matching signs
 Fishermen collecting medicines before they go off for a
month to ‘fish’
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“…most of the people here have
nothing wrong with them…they come
everyday with a different complaint to
build up their personal store of drugs.
They ask for a specific drug even if the
symptoms don’t warrant that drug. So
as a result I don’t screen properly, I get
bored. It is dangerous because I could
miss the odd serious case this way.
Interview- rural clinic-health worker
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2. People receive treatment
required to recover
Drug non-availability
 Drug shortages were experienced in both user fee
and user fee removed centres
 Drugs leak to private sector
 Poly pharmacy and non adherence to national
treatment guidelines are very common
 Prescriptions are given that people cannot afford
Costs of referral to the nearest hospital
Costs associated with investigations (X-rays,
Laboratory tests etc)
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Adhere to advice
 Patients do not
take medicine as
advised
 People share
medicines in the
communities
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Sharing medicines
Respondent: When you take some drugs, the moment
you feel ok you quit the course and so you keep the
rest of the drugs. If someone else gets ill and if that
person comes to you for assistance you help out.
Interviewer: Who decides which medicines to give
and who should be given?
Respondent: It is us who just come up with that. If
someone is complaining of a headache and you
have panadol you just give. If someone has malaria
and you are ok and you have Fansidar then you just
dish it out.
Interview , rural clinic, community member
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Types of medicine shared
 Analgesics, antipyretics
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
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
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and anti-inflammatory
drugs (panadol, indicid,
brufen, asprin)
Antimalarial drugs
(Coartem, Fansidar),
Antibiotics (amoxyl),
Antipuretics (piriton),
Oral contraceptives,
TB treatment,
Various minerals and
vitamins for adults and
children.
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Conclusion (1)
 Evaluation of the two policies cost sharing
and user fee removal is only possible
within the actions taken
 Many contradictions exist: yes people
were put off but the increased utilization
may not have improved the health status
of the population to the extent intended.
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Conclusion (2)
Additional information is required to understand
 The extent to which the increase in utilisation is
for ‘collecting’ medicines for future use
 Who the people are who are barred access by
remaining costs or barriers
 The relation between availability of drugs and
provider behaviour (leaking drugs and non
adherence to treatment protocols)
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Thank you!
Ministry of Health
DFID
All participants
LSHTM
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