User fee removal in Zambia: What happened and what was the impact? A community focused study

1. 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

2. 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

3. Objectives of qualitative component Qualitative component of the User Fee Evaluation was designed to: • Inform the wider research protocol design • Assist with interpretation of the results • Explore in more depth areas that are not easy to investigate using quantitative methods

4. 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

5. Sites selected Total facilities n=25 Charging User Fees n=12 +1 (NGO) User Fees Removed n=12 Facilities close to the border n=4

6. 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?

7. Implementation of policies

8. 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.

9. “…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

10. “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

11. 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

12. “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

13. Impact of user fee removal Three conditions… • People are sick and in need of treatment in order to fully recover or to limit spread of a disease • Comprehensive treatment required to meet these needs is provided • People adhere to the advice given (follow through)

14. 1. People presenting at the facilities following removal of user fees included… • Those who did not use to come when fees were charged (primarily those living near the health facility and less poor) • People with diseases in the early stage • “We used to treat complications now we treat diseases” • Interview-rural clinic- health worker • People not considered to be ‘sick’ by health workers

15. 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’

16. “…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

17. 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)

18. Adhere to advice • Patients do not take medicine as advised • People share medicines in the communities

19. 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

20. Types of medicine shared • Analgesics, antipyretics 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.

21. 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.

22. 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)

23. Thank you! Ministry of Health All participants DFID LSHTM