PHM-Exch> direct and indirect impact of user fees on access to malaria treatment and primary care in Mali

[Claudio Schuftan]

    From:    araceli_castro-sanjuan at hms.harvard.edu

Hidden Costs: The Direct and Indirect Impact of User Fees on Access to
Malaria Treatment and Primary Care in Mali, *Social Science &
Medicine*75:1786-1792; 2012.
By Ari Johnson, Adeline Goss, Jessica Beckerman, Arachu Castro.

Available at:
http://www.sciencedirect.com/science/article/pii/S0277953612005564.

Abstract

About 20 years after initial calls for the introduction of user fees in
health systems in sub-Saharan Africa, a growing coalition is advocating for
their removal. Several African countries have abolished user fees for
health care for some or all of their citizens. However, fee-for-service
health care delivery remains a primary health care funding model in many
countries in sub-Saharan Africa. Although the impact of user fees on
utilization of health services and household finances has been studied
extensively, further research is needed to characterize the multi-faceted
health and social problems associated with charging user fees. This
ethnographic study aims to identify consequences of user fees on gender
inequality, food insecurity, and household decision-making for a group of
women living in poverty. Ethnographic life history interviews were
conducted with women in Mali in 2007. Semi-structured interviews addressed
participants' past medical history, socio-economic status, social and
family history, and access to health care.  Interviews revealed that user
fees for health care not only decreased utilization of health services, but
also resulted in delayed presentation for care, incomplete or inadequate
care, compromised food security and household financial security, and
reduced agency for women in health care decision making. The effects of
user fees were amplified by conditions of poverty, as well as gender and
health inequality; user fees in turn reinforced the inequalities created by
those very conditions. The qualitative data illustrate that user fees for
health care may impact quality of care, health outcomes, food insecurity,
and gender inequality, in addition to impacting health care utilization and
household finances. As many countries consider user fee abolition policies,
these findings indicate the need to create a broader evaluation
framework—one that can measure the health and socioeconomic impacts of user
fee polices and of their removal.
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