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Removal of User Fees at Primary Health Care Level in Zambia Improving Financial Access to Health Services 2-4 November PowerPoint Presentation
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Removal of User Fees at Primary Health Care Level in Zambia Improving Financial Access to Health Services 2-4 November 2010. Dakar, Senegal. Outline of the Presentation. Background to free health services- 70s/80s User fees introduction -1993 Pre - user fees policy removal-2004

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Removal of User Fees at Primary Health Care Level in ZambiaImproving Financial Access to Health Services 2-4 November 2010

Dakar, Senegal

outline of the presentation
Outline of the Presentation
  • Background to free health services- 70s/80s
  • User fees introduction -1993
  • Pre - user fees policy removal-2004
  • Removal of user fees at primary health care level in Zambia 2006/07
  • Post - user fees policy 2007-2010
  • Conclusion
providers of health services in zambia
Providers of Health Services in Zambia
  • MOH facilities, facilities under the Ministry of Defense ,and Ministry of Home Affairs (86%)
  • Churches Health Association of Zambia (CHAZ) (7%)
  • private hospitals and clinics( 6%)
  • NGOs and traditional healers.
  • MOH ( 94% HC & HP, 5% Provincial and District Hospitals and 1% Tertiary Level)
the 60s 70s and early 80s good performing economy
The 60s,70s and early 80s..Good Performing Economy
  • Post independence economy – sound, vibrant, growing mineral based economy
    • Industrialization
    • Strong currency
  • No user fees =>
    • Introduction of “free” health care
    • Introduction of “free” education

L. Chileshe

poorly performing economy early 80s 90s
Poorly performing economy early 80s, 90s
  • Declining terms of trade
  • High poverty levels
  • Structural Adjustment Programmes
    • Reduced social sector expenditures among other aspects

L. Chileshe

reasons for user fees introduction
Reasons for User Fees Introduction
  • Cost Sharing as a means of resource mobilisation
  • To introduce “Ownership and partnership” by individuals, households and communities
  • Increase accountability in performance and transparency among the members of staff

L. Chileshe

other reasons for user fees intro
Other Reasons for User Fees Intro….
  • Better programme implementation, flexibility, and predictability in the use of funds at facility level
  • Avoid frivolous/abuse in the use of health facilities
  • Strengthen the use of health facilities through the referral system

L. Chileshe

prior to removal of user fees
Prior to Removal of User Fees
  • In 2004 the MoH commissioned a series of studies to review the situation with HCF in Zambia and provide suggestions for a future policy framework.
  • The first study was to review the performance of user fees in public facilities-focusing on the role of user fees in rural facilities
  • The second study looked at the feasibility of social health insurance in Zambia.
prior to removal of user fees cont
Prior to Removal of User Fees Cont…
  • The third study was a comprehensive review of existing financing mechanisms.
  • The purpose was to use the findings from these studies to feed into an overall financing strategy.
  • report was presented to the Ministry around August 2005.
some key findings issues
Some Key findings/issues
  • User fees as access barrier;
  • Limited financial contribution;
  • Change in international mood (seen also in Zambia).
  • Increasing poverty levels = average 80% in rural areas and 35% in urban areas
  • Belief in the RIGHT to GOOD HEALTH for ALL
  • Evidence from the ZDHS showed that about 40% of Zambian could not affordable to access health care due to cost
  • To protect poor people from financial catastrophe associated with having to pay for services.
notable confounding factors
Notable confounding factors:
  • Dissolution of CBOH in 2005/2006
  • Kwacha (exchange rate) volatility over the period
  • Drug shortage in 2006
  • Elections in 2006

L. Chileshe

abolition of user fees
Abolition of User Fees
  • January 2006, user fees were abolished in 54 out of 72 districts in Zambia effective 1st April 2006
  • The removal policy was extended to peri-urban areas in mid-2007 applicable outside a radius of 15Km and 20Km in Municipalities and Cities, respectively

L. Chileshe

post removal of user fees
Post Removal of User Fees
  • Utilisation
  • Revenue tracking
  • Drug availability
  • Job satisfaction & motivation

Broad Objective:

To assess the impact and processes of implementation of the user fee removal policy in Zambia’s health sector



  • Ministry of Health (MOH) - DPP
  • UNZA – Econ Department
  • DIFD
  • UCT
  • Segmented linear trend analysis

While accounting for trends before and after

Indicator variable capturing the “Short-term” impact of the policy change

revenue tracking
Revenue tracking

To determine the revenue impacts of user fee removal

  • Levels of formal user fee charges applied by health districts and facilities in selected areas for different health care services before and after the removal of user fees.
  • Significance (size and importance) of revenues mobilized – from various sources, particularly user fees – by health facilities in selected health areas where user fees were removed compared to areas where fees are still applied.
  • Key effects at district and facility level – in selected areas – of removing/maintaining user fees.
  • Exemption policy in areas where this policy applies/applied.
  • To track the implementation of the DFID user fee revenue replacement fund & other special compensation.
importance of uf revenue cont d
Importance of UF Revenue (cont’d)

On the ‘plus’ side:

  • Flexibilities (esp. at critical moments) was important.
  • Size relative to running costs was significant.
  • Predictability relative to running costs was clear.
  • Referral flow system was protected by bypass fees.
  • Local level ownership (facility and community level understanding).

On the ‘minus’ side:

  • Access barrier??
    • UF payments vs. Overall Household Health (OOP) Payments
  • Collection efficiency??
other revenue observations
Other Revenue observations

District (basket) grant:

  • Has increased even in real terms (esp. 2007 & 2008); partly to compensate for loss of revenue (PTO...)
    • Recent instabilities not accounted for...
  • Districts face challenges in allocating increase to components that ‘replace’ user fees and therefore compensate for losses.

Replacement grant:

  • Payment made to 1st wave districts and facilities.
  • Exact amount not clearly understood, esp. at facility and community levels.
  • Was a one-off (not sustained mechanism) – dynamics...
drug availability
Drug availability

To explore drug availability around the time of fee removal

  • Assess supply & days of stock-out of six essential drugs 2005-2008;
  • Determine the availability of 20 drugs and 5 supplies at time of visit;
  • Assess drug availability based on the fill-rate of patients’ prescription;
  • To document the impact of user fee removal on drug availability from a providers’ and patients’ perspective;


  • Within facility: ‘before & after’
  • Between facilities: UF vs. UFR
  • Descriptive analysis per facility (case studies)
availability 2005 2008
Availability 2005 - 2008

Days of stock-out per month 2005-2008, S/P & TEO, UF vs. UFR facilities

Drug availability mostly depending on supply-side factors

drug availability at day of visit
Drug availability at day of visit
  • In non-charging facilities 19.7of the 25 drugs & supplies were available, vs. 20.0 in charging facilities
    • Rural non-charging health centres especially poor-performing:

Additional challenges: roads, transport, qualified HR

    • Mission hospitals had better availability

Substantial additional support, sources outside of MSL

“There are drug shortages in that we are given fewer drugs. And I don't get better so we don't get the correct drugs. Before, I got better with the drugs I got” – female, 19 years, rural health centre

results drug availability
Results: drug availability
  • Data show large fluctuations in stock-outs between 2005-2008, mirroring supply-side problems
  • Wide variation between facilities:

Rural health centres more affected

Mission hospitals less affected (more support)

  • Many accounts by both health workers and patients of negative impact of policy change on drug availability

“UFR has not changed anything for the patients, instead it has worsened their suffering because of no medicine” – M&E officer, rural health centre

    • The national-level supply chain system and good stock management at facility level seemed most important for ensuring drug availability
job satisfaction motivation
Job satisfaction & motivation

To assess the impact of the removal of user fees on measures of staff motivation & job satisfaction

  • Assess level of job satisfaction for different domains investigated
  • Compare job satisfaction between staff working in charging and non-charging facilities
  • Explore how staff in non-charging facilities feel the removal of user fees has changed their personal situation, and that of the patients

Methods & analysis

  • Self-administered questionnaires: level of agreement and satisfaction in key areas & identification of underlying themes with Principal Component Analysis
results job satisfaction
Results: job satisfaction
  • Analysis of self-administered questionnaire showed that staff in rural non-charging facilities were more satisfied; however, this difference could be attributed to mission facilities in rural areas;
  • Health workers seemed to be supportive of the policy change, as long as it is accompanied by additional human & financial resources and medicines;

“ On the part of patients, it has encouraged them to come to the health centre whenever they feel unwell, unlike when they had to work for the user fee before they are attended to. Now everyone, also the poorest, can come. On the other hand, the health centre is struggling in raising enough funds to run it because money from the government is not enough. I suggest if the government would increase and not the patients to pay” – pharmacy dispenser, rural hospital

conclusions case studies
Conclusions: Case studies
  • The policy change has translated in free care in most facilities, but lack of clear guidelines and lack of protection mech. may have undermined the referral system.
  • Contextual issues specific for each facility have influenced the impact of fee removal on utilization rates.
  • User fee revenues were/are not negligible relative to grant running costs, and are more flexible (they make/made a difference, esp. at facility level).
  • Drug availability is influenced mainly by supply-side factors, not the removal of fees per se.
conclusions case studies cont d
Conclusions: case studies (cont’d)
  • The influence of user fee removal on job satisfaction and motivation requires further analysis.
  • User fee removal requires a lot of preparation; in the current context of systemic weakness and financing instabilities, caution should be exercised before scaling-up.
  • User fee removal is just one piece of the puzzle, and should be regarded as part of larger health sector reforms to and improve access to quality care & treatment for all; accompanying HSS components are critical to sustain utilization and to iron out short-terms instabilities.

Thank you