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User fee removal in Zambia: User fee removal in Zambia: What happened and what What happened and what

was the impact?was the impact?

A community focused studyA community focused study

AfHEA ConferenceAfHEA ConferenceAccra, GhanaAccra, Ghana

!0!0thth-12-12thth March 2009 March 2009

Mary Hadley, Lead ResearcherMary Hadley, Lead Researcher Collins Chansa, Ministry of HealthCollins Chansa, Ministry of Health

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Outline Outline

Objectives of the studyObjectives of the study MethodsMethods Implementation of policyImplementation of policy Potential impact on health of populationPotential impact on health of population -who attends?-who attends? -what they get?-what they get? -did they follow advice?-did they follow advice? ConclusionConclusion

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Objectives of qualitative componentObjectives of qualitative component

Qualitative component of the User Fee Qualitative component of the User Fee Evaluation was designed to:Evaluation was designed to:

1.1. Inform the wider research protocol Inform the wider research protocol designdesign

2.2. Assist with interpretation of the resultsAssist with interpretation of the results

3.3. Explore in more depth areas that are not Explore in more depth areas that are not easy to investigate using quantitative easy to investigate using quantitative methodsmethods

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Methods (1)Methods (1)

A team of international A team of international and national researchers and national researchers

Interviews n=(99), Interviews n=(99), discussions (n=23) and discussions (n=23) and observations (n=14) observations (n=14)

Key informants Key informants Users, non users, health Users, non users, health

providers and community providers and community volunteers and committee volunteers and committee members participated. members participated.

Discussion in a rural area with Neighbourhood Health Committee members

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Sites selectedSites selectedGovernmentGovernment Faith-based/NGOFaith-based/NGO RuralRural UrbanUrban

HospitalsHospitals 5 5 3 user fees 3 user fees 2 fees removed2 fees removed

2 2 Both fees removedBoth fees removed

(3)(3) (4)(4)

HealthHealthCentresCentres

15 15 8 user fees 8 user fees 7 fees removed7 fees removed

3 3 1 user fees 1 user fees 1 fees removed1 fees removed1 NGO 1 NGO

(5)(5) (13) (13) 8 user fees, 8 user fees, 4 fees removed ‘07 4 fees removed ‘07 1 NGO1 NGO

TotalTotal 2020 55 (8)(8) (17)(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)Methods (2)

Building on existing Building on existing information, three information, three broad questions were broad questions were used as the framework used as the framework for data collection. for data collection.

Data generated was Data generated was triangulated for triangulated for validation purposes validation purposes and themes identified and themes identified

What do people do What do people do when they get sick?when they get sick?

What happens if they What happens if they go to a health facility?go to a health facility?

What do they do What do they do when they get home?when they get home?

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Implementation of policiesImplementation of policies

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Cost sharing policy Cost sharing policy

Community involvement in setting and using Community involvement in setting and using user fees was patchyuser fees was patchy

Exemption policy for categories such as under Exemption policy for categories such as under 5s and over 65s and to some extent chronic 5s and over 65s and to some extent chronic conditions and pregnant women were broadly conditions and pregnant women were broadly adhered toadhered to

However, and importantly, exemption criteria for However, and importantly, exemption criteria for ‘those who are unable to afford’ was not ‘those who are unable to afford’ was not uniformly exercised leading to delays and uniformly exercised leading to delays and deaths in the communities. deaths in the communities.

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“…“…their niece got sick, she went to their niece got sick, she went to the clinic and was asked to pay the clinic and was asked to pay K1,500 and then she informed K1,500 and then she informed them that she didn’t have the them that she didn’t have the

money, they sent her back, when money, they sent her back, when she got home, the father and she got home, the father and

mother were away, when they just mother were away, when they just returned home three days later returned home three days later

they found a copse.”they found a copse.” Interview- urban district-policeInterview- urban district-police

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““The other case, they didn't even take a The other case, they didn't even take a stab at going to the facility because stab at going to the facility because

they knew that even if they went there, they knew that even if they went there, they wouldn't be attended to because they wouldn't be attended to because

they didn’t have the K1,500 for they didn’t have the K1,500 for treatment which the clinic asks for.....so treatment which the clinic asks for.....so

in the process of giving traditional in the process of giving traditional medicines, she died whilst at home”medicines, she died whilst at home”interview- urban district (fees removed in 2007)-policeinterview- urban district (fees removed in 2007)-police

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Removal of user fee policyRemoval of user fee policy

Not all eligible centres had removed charges Not all eligible centres had removed charges Fees for registration, investigations and Fees for registration, investigations and

referrals continued to be charged. referrals continued to be charged.

Additional reasons for not accessing health Additional reasons for not accessing health facilities facilities Distance from the health facility, lack Distance from the health facility, lack of suitable clothing to attend the clinics/ no of suitable clothing to attend the clinics/ no soap, negative staff behaviour towards soap, negative staff behaviour towards patients, waiting times, alternatives availablepatients, waiting times, alternatives available

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““We have people in this community We have people in this community that can still not afford to buy a that can still not afford to buy a

book for K500. some people are book for K500. some people are aware that you do not pay user aware that you do not pay user fees at the clinic because they fees at the clinic because they

have been removed. But they still have been removed. But they still cannot afford to buy a book for cannot afford to buy a book for K500. Such people are there”.K500. Such people are there”.

Group discussion- rural clinic-usersGroup discussion- rural clinic-users

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Impact of user fee removalImpact of user fee removal

Three conditions…Three conditions…1.1. People are sick and in People are sick and in

need of treatment in need of treatment in order to fully recover or order to fully recover or to limit spread of a to limit spread of a diseasedisease

2.2. Comprehensive Comprehensive treatment required to treatment required to meet these needs is meet these needs is providedprovided

3.3. People adhere to the People adhere to the advice given (follow advice given (follow through)through)

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1. People presenting at the 1. People presenting at the facilities following removal of user facilities following removal of user

fees included…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 We used to treat complications now we treat

diseases” diseases” Interview-rural clinic- health workerInterview-rural clinic- health worker

3.3. People not considered to be ‘sick’ by health People not considered to be ‘sick’ by health workersworkers

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People who were not considered to People who were not considered to be ‘sick’ by health workersbe ‘sick’ by health workers

Reports of …Reports of … people coming with only a thorn prick, aching muscles people coming with only a thorn prick, aching muscles

from working in the fieldsfrom working in the fields People just coming into the health centre because they People just coming into the health centre because they

happen to be in the vicinity, collecting medicines to go happen to be in the vicinity, collecting medicines to go homehome

People pretending to be ill, requesting medicines that do People pretending to be ill, requesting medicines that do not fit the signs and symptomsnot fit the signs and symptoms

Mothers bringing all the children in at the same time with Mothers bringing all the children in at the same time with vague symptoms and no matching signsvague symptoms and no matching signs

Fishermen collecting medicines before they go off for a Fishermen collecting medicines before they go off for a month to ‘fish’month to ‘fish’

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“…“…most of the people here have most of the people here have nothing wrong with them…they come nothing wrong with them…they come everyday with a different complaint to everyday with a different complaint to build up their personal store of drugs. build up their personal store of drugs. They ask for a specific drug even if the They ask for a specific drug even if the symptoms don’t warrant that drug. So symptoms don’t warrant that drug. So as a result I don’t screen properly, I get as a result I don’t screen properly, I get bored. It is dangerous because I could bored. It is dangerous because I could

miss the odd serious case this way.miss the odd serious case this way. Interview- rural clinic-health workerInterview- rural clinic-health worker

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2. People receive treatment 2. People receive treatment required to recoverrequired to recover

Drug non-availabilityDrug non-availability Drug shortages were experienced in both user fee Drug shortages were experienced in both user fee

and user fee removed centresand user fee removed centres Drugs leak to private sectorDrugs leak to private sector Poly pharmacy and non adherence to national Poly pharmacy and non adherence to national

treatment guidelines are very commontreatment guidelines are very common Prescriptions are given that people cannot affordPrescriptions are given that people cannot afford

Costs of referral to the nearest hospital Costs of referral to the nearest hospital

Costs associated with investigations (X-rays, Costs associated with investigations (X-rays, Laboratory tests etc)Laboratory tests etc)

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Adhere to adviceAdhere to advice

Patients do not Patients do not take medicine as take medicine as advisedadvised

People share People share medicines in the medicines in the communitiescommunities

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Sharing medicinesSharing medicines Respondent:Respondent: When you take some drugs, the moment When you take some drugs, the moment

you feel ok you quit the course and so you keep the you feel ok you quit the course and so you keep the rest of the drugs. If someone else gets ill and if that rest of the drugs. If someone else gets ill and if that person comes to you for assistance you help out. person comes to you for assistance you help out.

Interviewer:Interviewer: Who decides which medicines to give Who decides which medicines to give and who should be given? and who should be given?

Respondent:Respondent: It is us who just come up with that. If It is us who just come up with that. If someone is complaining of a headache and you someone is complaining of a headache and you have panadol you just give. If someone has malaria have panadol you just give. If someone has malaria and you are ok and you have Fansidar then you just and you are ok and you have Fansidar then you just dish it out.dish it out.

Interview , rural clinic, community memberInterview , rural clinic, community member

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Types of medicine sharedTypes of medicine shared Analgesics, antipyretics Analgesics, antipyretics

and anti-inflammatory and anti-inflammatory drugs (panadol, indicid, drugs (panadol, indicid, brufen, asprin) brufen, asprin)

Antimalarial drugs Antimalarial drugs (Coartem, Fansidar), (Coartem, Fansidar),

Antibiotics (amoxyl), Antibiotics (amoxyl), Antipuretics (piriton), Antipuretics (piriton), Oral contraceptives, Oral contraceptives, TB treatment, TB treatment, Various minerals and Various minerals and

vitamins for adults and vitamins for adults and children.children.

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Conclusion (1)Conclusion (1)

Evaluation of the two policies cost sharing Evaluation of the two policies cost sharing and user fee removal is only possible and user fee removal is only possible within the actions takenwithin the actions taken

Many contradictions exist: yes people Many contradictions exist: yes people were put off but the increased utilization were put off but the increased utilization may not have improved the health status may not have improved the health status of the population to the extent intended.of the population to the extent intended.

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Conclusion (2)Conclusion (2)

Additional information is required to understandAdditional information is required to understand The extent to which the increase in utilisation is The extent to which the increase in utilisation is

for ‘collecting’ medicines for future use for ‘collecting’ medicines for future use Who the people are who are barred access by Who the people are who are barred access by

remaining costs or barriersremaining costs or barriers The relation between availability of drugs and The relation between availability of drugs and

provider behaviour (leaking drugs and non provider behaviour (leaking drugs and non adherence to treatment protocols)adherence to treatment protocols)

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Thank you!Thank you!

DFIDLSHTM

Ministry of Health

All participants