Why increased utilisation of primary care services following the removal of user fees does not equate to access to the poor
Background: The provision of health services, free at the point of delivery, is considered by many organisationsto be one of the most important policies to improve access to the most vulnerable in society (Pearson 2004). Therefore, ahead of the 2006 Zambiannational elections and with considerable backing from external aid agencies, user fees were removed in all rural Districts ofthe country. The result was an increase in the number of patients presenting for curative consultations at primary health centresin these Districts (Masiyeet al 2010). Those in favourof removal of user fees declared the policy to be a success based on this increased utilisation. However, qualitative research was undertaken to study the effects of the policy on the most vulnerable (Hadley 2011). Interviewers conducted in-depth interviews and held focus group discussions with users and non-users of the health services and health care providers.
Key results: The results indicated that barriers to access that were beyond the nominal fee for curative services. Charges for the ‘book’ used for patients’ records continued. Transport and other indirect costs also remained. If a person did not have soap to wash or ‘nice’ clothes to wear they did not attend the nearest health centrefor fear of being ridiculed. The increased utilisation, the study found, comprised primarily of those living near to the health centres. Clinicians, fatigued by constant demands for the available ‘free’ drugs, prescribed at the clients’ requests, even when their medical knowledge and clinical guidelines directed them otherwise. They accused the patients of building up ‘small pharmacies’ at home to administer medicines to friends and family.
Policy implications: The interpretation of the quantitative evaluation of the removal of user fees policy was that the poor had more access to health services after user fees were abolished. The qualitative evaluation indicated this was not so and that the introduction of a user fee removal policy was insufficient to ensure access to basic curative health services by the most vulnerable in rural Zambia.