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Gender Dimensions of User Fees: Implications for Women’s Utilization of Health Care
Abstract
This paper looks at the implications of user fees for women's utilization of health care services, based on selected studies in Africa. Lack of access to resources and inequitable decision-making power mean that when poor women face out-of-pocket costs such as user fees when seeking health care, the cost of care may become out of reach. Even though many poor women may be exempt from fees, there is little incentive for providers to apply exemptions, as they too are constrained by restrictive economic and health service conditions. If user fees and other out-of-pocket costs are to be retained in resource-poor settings, there is a need to demonstrate how they can be successfully and equitably implemented. The lack of hard evidence on the impact of user fees on women's health outcomes and reproductive health service utilization reminds us of the urgent need to examine how women cope with health care costs and what trade-offs they make in order to pay for health care. Such studies need to collect gender-disaggregated data in relation to women's health service utilization and in relation to the range of reproductive health services, taking into account not only out-of-pocket fees charged by public health providers but also by private and traditional providers.
... The major determinants of the low rates of reproductive health service utilization among women in Lao PDR as well as that in other low socioeconomic settings were assumed to be related to lower level of education [3][4][5][6] , lack of knowledge 7) , being of young age 8) , high birth order 8) , un-employment 9) , low service accessibility 10) , hidden costs of treatment 10) , remoteness 11) , and poor socioeconomic status 12) . However, studies performed to date have typically not taken into consideration the roles of psychosocial factors in women's utilization of reproductive health services. ...
... The major determinants of the low rates of reproductive health service utilization among women in Lao PDR as well as that in other low socioeconomic settings were assumed to be related to lower level of education [3][4][5][6] , lack of knowledge 7) , being of young age 8) , high birth order 8) , un-employment 9) , low service accessibility 10) , hidden costs of treatment 10) , remoteness 11) , and poor socioeconomic status 12) . However, studies performed to date have typically not taken into consideration the roles of psychosocial factors in women's utilization of reproductive health services. ...
... Control variables: We incorporated sociodemographic variables theoretically and analytically related to the utilization of reproductive health services [4][5][6][7][8][9][10][11][12] and acceptance of partner abuse [22][23][24] . We codified the participants based on their current age, into the following three broad groups according to their fertility and reproductive behavior: ado-lescence (1 = 15-19 years), young adult (2 = 20-34 years), and older (3 = 35-49 years). ...
Objective: Evidence from developing countries on the association between women’s endorsement of attitudes justifying partner abuse and their use of reproductive health services is suggestive but inconclusive. This study uses a nationally representative dataset from Lao PDR to provide strong evidence for the relationship between women’s endorsement of attitudes justifying partner abuse and use of reproductive health services.
Methods: This study used data from the 2011–2012 Lao Social Indicator survey (LSIS). The analyses were performed on the responses of 4227 women. The exposure of interest in this study was endorsement of attitudes justifying partner abuse. Antenatal care (ANC) visits divided according to amount and quality, delivery care by type and place, and utilization of postnatal care (PNC) for mothers and newborn infants were used as representative outcome variables of reproductive health service utilization.
Results: Approximately seven out of ten respondents (67.9%) believed that partner abuse was justified. Women who endorsed these attitudes were significantly less likely to receive any ANC, to seek institutional delivery, and to use trained medical personnel for delivery assistance. Endorsing attitudes were associated with reduced probability of receiving PNC services for mothers and newborn infants, reduced frequency of ANC visits, and receiving a fewer number of ANC components. Other sociodemographic factors likely to affect the increased utilization of several of the indicators of reproductive health care were living in the central region, belonging to the high bands of wealth, having higher level of education, being a young adult (20–34 years) or older (35–49 years), residing in urban areas, and being sexually empowered.
Conclusions: In addition to a broad range of sociodemographic factors, our findings suggested that women’s endorsement of attitudes justifying partner abuse should be treated as an important psychosocial determinant of reproductive health care service utilization in Lao PDR.
... It is against this background that the CRS government, through the MOH and Tulsi Chanri Foundation, decided to provide free MHC for all pregnant women in the state, (PROJECT HOPE) in 2009, to improve maternal health service utilisation and meet MDG5 by 2015. The purpose of such policies is to address equity issues by increasing health facility use and reducing catastrophic out of pocket payment [13][14][15][16]. Since its inception, there has been no formal evaluation of the effectiveness of this program. ...
... The impact of user fees protects the poor by reducing catastrophic out of pocket payment [13,16]. Some developing countries with high MMR have adopted free maternal health care (FMHC) policy at national or state levels, as an intervention intended to tackle maternal mortality. ...
... In SSA, user fees as a form of financing maternal health have adversely affected healthseeking behaviour among women [16]. Reviews from Ghana, Swaziland, Zaire, Uganda, Kenya, Nigeria and South Africa suggest that use of maternal health care service is greatly affected by introduction or removal of user fees [22][23][24]. ...
BACKGROUND: Increasing the percentage of maternal health service utilization in health facilities, through cost-removal policy is important in reducing maternal deaths. The Cross River State Government of Nigeria introduced a cost-removal policy in 2009, under the umbrella of “PROJECT HOPE” where free maternal health services are provided. Since its inception, there has been no formal evaluation of its effectiveness.
AIM: This study aims to evaluate the effect of the free maternal health care program on the health care-seeking behaviours of pregnant women in Cross River State, Nigeria.
METHOD: A mixed method approach (quantitative and qualitative methods) was used to describe the effect of free maternal health care intervention. The quantitative component uses data on maternal health service utilisation obtained from PROJECT HOPE and Nigeria Demographic Health Survey. The qualitative part uses Focus Group Discussions to examine women's perception of the program.
RESULTS: Results suggest weak evidence of change in maternal health care service utilization, as 95% Confidence Intervals overlap even though point estimate suggest increase in utilization. Results of quantitative data show increase in the percentage of women accessing maternal health services. This increase is greater than the population growth rate of Cross River State which is 2.9%, from 2010 to 2013. This increase is likely to be a genuine increase in maternal health care utilisation. Qualitative results showed that women perceived that there have been increases in the number of women who utilize Antenatal care, delivery and Post Partum Care at health facilities, following the removal of direct cost of maternal health services. There is urban and rural differences as well as between communities closer to health facility and those further off. Perceived barriers to utilization are indirect cost of service utilization, poor information dissemination especially in rural areas, perceived poor quality of care at facilities including drug and consumables stock-outs, geographical barriers, inadequate health work force, and poor attitude of skilled health workers and lack of trust in the health system.
CONCLUSION: Reasons for Maternal health care utilisation even under a cost-removal policy is multi-factorial. Therefore, in addition to fee-removal, the government must be committed to addressing other deterrents so as to significantly increase maternal health care service utilisation.
... At a household level, among Kenyan women who had experienced high-risk births in both countries, women from middle or higher household wealth status were at least one and half times more likely to be using contraceptive compared to women from low household incomes. This could be explained by the fact that women who have financial resources have better access to sexual reproductive health services including contraceptives [28,29]. It is also supported by our finding that, at community level in Zimbabwe, higher levels of poverty were associated with reduced odds of contraceptive usage. ...
... We also found that maternal education was associated with reduced odds of high risk births and under-five mortality in both countries even though this was more evident in Zimbabwe. It is hypothesised that education protects against high-risk births because young women spend more years in school delaying delivery before 18 years, become more aware of available methods of contraception and tend to be employed, thus have income which can improve their access to health care including contraceptive services [28,29,31]. Maternal education provides autonomy in decision making which increases the mother's ability to access health care for children in a household, thus ultimately contributing to the reducing under-five mortality [32]. ...
Background
Increasing uptake of modern contraception is done to alleviate maternal and infant mortality in poor countries. We describe prevalence of contraceptive use, high risk births, under-five mortality and their risk factors in Kenya and Zimbabwe.
Methods
This was a cross-sectional analysis on DHS data from Kenya (2014) and Zimbabwe (2011) for women aged 15–49. Geospatial mapping was used to compare the proportions of the following outcomes: current use of contraceptives, high-risk births, and under-5 mortality at regional levels after applying sample weights to account for disproportionate sampling and non-responses. Multivariate risk factors for the outcomes were evaluated by multilevel logistic regression and reported as adjusted odds ratios (aOR).
Results
A total of 40,250 (31,079 Kenya vs. 9171 Zimbabwe) women were included in this analysis. Majority were aged 18–30 years (47%), married/cohabiting (61%) and unemployed (60%). Less than half were using contraceptives (36% Kenya vs. 41% Zimbabwe). Spatial maps, especially in the Kenyan North-eastern region, showed an inverse correlation in the current use of contraceptives with high risk births and under-5 mortality. At individual level, women that had experienced high risk births were likely to have attained secondary education in both Kenya (aOR = 5.20, 95% CI: 3.86–7.01) and Zimbabwe (aOR = 1.63, 95% CI: 1.08–2.25). In Kenya, high household wealth was associated with higher contraceptive use among both women who had high risk births (aOR: 1.72, 95% CI: 1.41–2.11) and under-5 mortality (aOR: 1.66, 95% CI: 1.27–2.16). Contraceptive use was protective against high risk births in Zimbabwe only (aOR: 0.79, 95% CI: 0.68–0.92) and under-five mortality in both Kenya (aOR: 0.79, 95% CI: 0.70–0.89) and Zimbabwe (aOR: 0.71, 95% CI: 0.61–0.83). Overall, community levels factors were not strong predictors of the three main outcomes.
Conclusions
There is a high unmet need of contraception services. Geospatial mapping might be useful to policy makers in identifying areas of greatest need. Increasing educational opportunities and economic empowerment for women could yield better health outcomes.
Electronic supplementary material
The online version of this article (10.1186/s12905-018-0666-1) contains supplementary material, which is available to authorized users.
... [8][9][10][11][12][13] User fees are one such (financial) barrier discouraging FBD utilisation. 10,[14][15][16] Health system factors such as quality also matter. 17 Although the importance of quality has been confirmed in qualitative study, 18 few quantitative studies manage to capture the quality of care. ...
... 24,35 However, in a review of 20 articles, the abolition of user fees has generally been found to have positive effects on the utilisation of health services. 41 With regard to maternal health services, as would be expected, user fees have had negative effects on utilisation, 14 while abolition has had the opposite effect. 31 Although user fees do matter, up to 20 other determinants have been identified. ...
Background:
Maternal health remains a concern in sub-Saharan Africa, where maternal mortality averages 680 per 100,000 live births and almost 50% of the approximately 350,000 annual maternal deaths occur. Improving access to skilled birth assistance is paramount to reducing this average, and user fee reductions could help.
Objective:
The aim of this research was to analyse the effect of user fee removal in rural areas of Zambia on the use of health facilities for childbirth. The analysis incorporates supply-side factors, including quantitative measures of service quality in the assessment.
Method:
The analysis uses quarterly longitudinal data covering 2003 (q1)-2008 (q4) and controls for unobserved heterogeneity, spatial dependence and quantitative supply-side factors within an Interrupted Time Series design.
Results:
User fee removal was found to initially increase aggregate facility-based deliveries. Drug availability, the presence of traditional birth attendants, social factors and cultural factors also influenced facility-based deliveries at the national level.
Conclusion:
Although user fees matter, to a degree, service quality is a relatively more important contributor to the promotion of facility-based deliveries. Thus, in the short-term, strengthening and improving community-based interventions could lead to further increases in facility-based deliveries.
... This is because developing economies are highly informal, limiting revenue mobilization by the government to finance healthcare and other basic infrastructures (World Bank, 2019). OOP payments made by individuals to public healthcare providers at the point of service delivery are often referred to as user charges (Nanda, 2002;Lagarde and Palmer, 2008). Such payments can be in the form of registration charges, entrance or consultation fees, drug costs, medical laboratory requirements or charges for any healthcare use whether inpatient or outpatient cares (Lagarde and Palmer, 2008;Ejughemre, 2014). ...
Purpose
This study investigates the effect of user fees on access and waiting time in Nigeria. For access, the effect of user fees on both preventive and curative care; and the effect of user fees on waiting time at public healthcare facilities were examined. User fees are vital for the fiscal sustainability of healthcare provision for most African economies. Its imposition could debar healthcare access by the poor while its removal can reduce quality of care and induce longer waiting time.
Design/methodology/approach
The wave 3 of the Nigerian General Household Survey (2015/16) data was used for users of public health facilities. Access to healthcare was modelled using utilization data in a logistic regression model while waiting time was through the Negative Binomial Regression Model (NBRM).
Findings
The analyses showed significant effects of user fees on access to both preventive and curative care and on time spent waiting to make use of healthcare services. Individuals were able to access healthcare services regardless of amounts paid. Also, there was a non-negative effect of user fee imposition on waiting time.
Practical implications
Nigeria should improve healthcare facilities to address the enormous demand for healthcare services when designing policy for health sector.
Originality/value
This paper shows that even with the imposition of user fees, healthcare facilities could still not cater for the rising healthcare needs of the populace but cautioned that its abolition may not be a preferred option.
... Bello and Ambrose (2006) argue that the conditionalities imposed by the IMF and the World Bank, that governments of poor countries cut spending on public institutions, cut subsidies to farmers, privatize public services such as health care, education, water and electricity, as a prerequisite for receiving "help" (including loans) is what deepened poverty. Nanda (2002) shows, for example, how in healthcare a user fee, introduced as part of cost recovery within a SAP led to decreased health service utilization in Ghana, Swaziland, Zaire and Uganda. In another twist, while the poor countries were forced to cut subsidies to their farmers, the rich countries in the north not only subsidize their farmers, but also in essence close their markets for products from the poor countries, while at the same time flooding the south with products that push local farmers out of business (Maren, 1997). ...
The COVID-19 pandemic has made visible inequalities as exemplified by unequal access to COVID-19 vaccine across and within countries; inequalities that are also apparent in rates of testing, disease, hospitalization and death from COVID-19 along class, ethnic and racial lines. For a global pandemic such as the COVID-19 to be effectively addressed, there is a need to reflect on the entrenched and structural inequalities within and between countries. While many countries in the global north have acquired more vaccines than they may need, in the global south many have very limited access. While countries in the global north had largely vaccinated their populations by 2022, those in the global south may not even complete vaccinating 70% of their population to enable them reach the so-called herd immunity by 2024. Even in the global north where vaccines are available, ethnic, racialized and poor working classes are disproportionately affected in terms of disproportionately low rates of infection and death. This paper explores the socio-economic and political structural factors that have created and maintain these disparities. In particular we sketch the role of neoliberal developments in deregulating and financializing the system, vaccine hoarding, patent protection and how this contributes to maintaining and widening disparities in access to COVID-19 vaccine and medication.
... What are not accounted for in these models are the consequences of an inability to pay. In the field of health care, for example, Nanda (2002) found that women's rates of utilisation of health care decreased dramatically in several African nations after the introduction of user fees, thus jeopardising women's health. Nanda similarly shows that maternal death rates increased by 56% in the Zaria region of Nigeria as a result of an inability to pay user fees. ...
... Similar findings have been reported in transition countries such as Kyrgyzstan, Cambodia, and the Kyrgyz Republic where informal payments reduced following the introduction of copayments alongside other initiatives 14,60,61 . However, user fees reduce the utilization of health services especially among the poor 62,63 , and therefore formalization of user fees in SSA would also require the implementation of effective exemption policies for the poor and other vulnerable groups 64 . The effectiveness of formalization of user fees in reducing informal payments also warrants further investigation since the effects were not sustained in some transition countries such as Kyrgyzstan 61 . ...
Background: Informal payments limit equitable access to healthcare. Despite being a common phenomenon, there is a need for an in-depth analysis of informal charging practices in the Sub-Saharan Africa (SSA) context. We conducted a systematic literature review to synthesize existing evidence on the prevalence, characteristics, associated factors, and impact of informal payments in SSA.
Methods: We searched for literature on PubMed, African Index Medicus, Directory of Open Access Journals, and Google Scholar databases and relevant organizational websites. We included empirical studies on informal payments conducted in SSA regardless of the study design and year of publication and excluded reviews, editorials, and conference presentations. Framework analysis was conducted, and the review findings were synthesized.
Results: A total of 1700 articles were retrieved, of which 23 were included in the review. Several studies ranging from large-scale nationally representative surveys to in-depth qualitative studies have shown that informal payments are prevalent in SSA regardless of the health service, facility level, and sector. Informal payments were initiated mostly by health workers compared to patients and they were largely made in cash rather than in kind. Patients made informal payments to access services, skip queues, receive higher quality of care, and express gratitude. The poor and people who were unaware of service charges, were more likely to pay informally. Supply-side factors associated with informal payments included low and irregular health worker salaries, weak accountability mechanisms, and perceptions of widespread corruption in the public sector. Informal payments limited access especially among the poor and the inability to pay was associated with delayed or forgone care and provision of lower-quality care.
Conclusions: Addressing informal payments in SSA requires a multifaceted approach. Potential strategies include enhancing patient awareness of service fees, revisiting health worker incentives, strengthening accountability mechanisms, and increasing government spending on health.
... Par conséquent, pour promouvoir un accès équitable aux soins, les acteurs de la santé mondiale et les gouvernements doivent tenir compte des contextes locaux et s'adapter à ces réalités lors de la conception des interventions de santé publique et, en fin de compte, des politiques (Aboagye et al., 2019; Thiede & Koltermann, 2013). Pour orienter les politiques, les recherches futures, avec l'application de méthodes mixtes, doivent se concentrer sur l'évaluation de la perspective locale du rôle et de l'interrelation des divers obstacles financiers et non financiers à l'accès et à l'utilisation des soins de santé de manière globale.À la lumière des résultats, une stratégie complémentaire aux mesures existantes pourrait consister à mieux lutter contre les inégalités entre les sexes par des interventions axées sur l'autonomisation, car les femmes sont encore moins susceptibles d'utiliser les services de santé en raison de leur pouvoir d'agir limité(Nanda, 2002). Pour améliorer radicalement la capacité des femmes à prendre des décisions en matière de santé, les gouvernements devront aller au-delà de simples réformes dans le secteur des soins desanté et introduire des politiques sociales et économiques qui renforcent la position des femmes dans l'ensemble de la société (Samb & Ridde, 2018). ...
Les politiques de réduction et de suppression des frais d'utilisation ont fait l'objet de recherches approfondies, mais il existe peu de preuves rigoureuses de leurs effets durables en ce qui concerne l'utilisation des services de soins. De plus, aucune preuve n'existe sur les effets d'une réduction partielle par rapport à la suppression totale des frais d'utilisation. Notre étude s'est déroulée dans quatre districts de la région du Sahel au Burkina Faso, où la politique nationale de réduction des frais d'utilisation (SONU) lancée en 2007 (réduction de 80/100 des frais d'utilisation) coexistait avec un projet pilote de suppression des frais d'utilisation lancé en 2008. Les résultats montrent que la SONU a produit une augmentation cumulée de 31,4/100 sur huit ans dans les quatre districts étudiés. Le projet pilote a encore amélioré l'utilisation et a produit une augmentation supplémentaire de 23,2/100 sur six ans. Les politiques de réduction et de suppression des frais d'utilisation ne suffisent pas à elles seules pour obtenir une couverture complète. Il est donc nécessaire de mettre en oeuvre des mesures supplémentaires, ciblant par exemple les barrières géographiques et les lacunes en matière de connaissances, afin que toutes les femmes accouchent en présence d'une personne qualifiée.
... Women are often more marginalised by the social costs of seeking health care. They also have specific needs for reproductive care (Nanda, 2002). Gender differences in responses to user fee change become obvious if we explore women-oriented health services such as maternal health services, which is the case in this study. ...
The effect of introducing or increasing user fees for health services in low- and middle-income countries is controversial. While user fees are advocated as an effective means of generating revenue and enabling health service quality improvement, they constitute a financial barrier to access health services for the poorer. This paper contributes to the literature on the demand-side financing in health by providing evidence on the medium-term effects of introducing user fees on the utilisation of family planning, antenatal and delivery care services, women’s access to health care, and child health status in a middle-income country setting. Using a difference-in-differences identification approach to establish causality, we find that the introduction of user fees in Egypt had no negative effect on the utilisation of family planning and delivery care services. Further, fees did not hinder women’s access to care and did not harm child health outcomes. Positive effects were even observed with respect to the utilisation of antenatal care services. Our findings are compatible with the hypothesis that the potential decrease in demand due to the user fee imposition might have been offset by an increased willingness to pay for a health care quality that could be, at least partly, perceived as higher.
... Although the majority of patients said that they would refer a sick friend or family member to the facility, female patients were less likely to refer the facility to a family member or friend. This could be because health service utilisation among women tends to be higher than among men [52][53][54], and the majority of patients in this study were women. Thus, their experiences of the facility may have influenced their responses on whether they would refer friends or family members. ...
Background: There is global emphasis on quality universal health coverage (UHC) that is responsive to the needs of vulnerable communities, such as migrants.
Objective: Examine the perceptions of migrants on health system responsiveness (HSR) and their satisfaction with health workers in public health facilities of a South African Province.
Method: We conducted a cross-sectional study in 13 public health facilities. Following informed consent, we used a semi-structured questionnaire to collect sociodemographic information, patient perceptions of HSR and their satisfaction with health workers. Two open-ended questions gave patients the opportunity to comment on the health facility visit. We applied descriptive and multivariate analyses to our data, and thematic analysis to the qualitative responses.
Results: A total of 251 migrant patients participated in the study, giving a response rate of 80.7%. The majority of patients were female (81.1%), and the mean age was 31.4 years. 30.0% of patients reported that they waited too long; 94.3% that the consulting nurse or doctor listened to them; and 89.4% that they received information about their condition. However, 81.7% said they did not know the name of the consulting nurse or doctor. The mean scores on patients’ satisfaction with health workers ranged from 7.0 (95% CI 6.42–7.63) for clerks, 7.7 (95% CI 7.4–8.0) for security guards, 7.4 (95% CI 7.1–7.6) for nurses and 8.3 (95% CI 7.93–8.63) for doctors. The predictors of patient satisfaction with nurses were being given information about their condition; polite treatment, time spent in facility, whether they received prescribed medicines; and stating that they would refer the health facility to family/friends. Four overlapping themes emerged: health workers’ attitudes; time waited at the health facility, communication difficulties; and sub-optimal procedures in the health facility.
Conclusion: UHC policies should incorporate migrant patients’ perceptions of HSR and the determinants of their satisfaction with health workers.
... Social, cultural, biological and economic differences between females and males are more likely to expose women to a higher global AMD burden [25,26], such as lower diagnostic and therapeutic efforts for women [27,28] and longer life expectancies for women [29]. A lack of nancial decision-making authority within the family and lower incomes may inhibit women from being able to pay for eye care services [30,31]. In addition, women's child care responsibilities may make it di cult for them to leave home to access more eye care. ...
Background: Age-related macular degeneration (AMD) is the third leading cause of blindness and affects approximately 196 million people. This study aims to explore the association of sex with the global burden of AMD by year, age, and socioeconomic status using disability-adjusted life-years (DALYs).
Methods: Global, national sex-specific DALY numbers, crude DALY rates, and age-standardized DALY rates caused by AMD, by year and age, were extracted from the Global Burden of Disease Study 2017. The human development index (HDI) in 2017 was extracted as an indicator of national socioeconomic status from the Human Development Report 2018 (HDR 2018). Pearson correlation and linear regression analyses were conducted to investigate the association between socioeconomic status and sex inequality of AMD.
Results: Differences in the sex-specific global burden of AMD have persisted since 1990 to 2017. Female individuals had higher burden than male individuals of the same age in 2017, and the differences gradually increased after 55 years and maximized at 80 years or older with 105.41 DALYs rates in female vs 81.00 DALYs rates in male. The paired Wilcoxon signed rank test indicated that female had higher age-standardized DALY rates than male had (Z = -6.520, P < 0.001) and countries with lower HDI values had higher age-standardized DALY rates among both sexes. DALY rate ratio and sex differences in age-standardized DALY rates were positively associated with HDI in both Pearson correlation analyses and linear regression analyses of AMD. (P < 0.05).
Conclusions: Although global blindness and vision impairment health care is progressing, sex inequality in AMD burden remained persistent since the past few decades. These findings might raise more public attention to the gender differences in global AMD burden and the association between the sex-related global burden and socioeconomic status.
... Where insurance schemes exist, maternal health care needs to be included in the benefits package, and careful design is needed to ensure uptake by the poorest people (Borghi et al., 2006). Studies from African countries show that even though many poor women may be exempt from fees, there is little incentive for providers to apply exemptions, as they too are constrained by restrictive economic and health service conditions (Nanda, 2002). ...
1 We are very grateful to the members and corresponding members of the WGEKN, and the authors of background papers for their willingness to write, read, comment and send material. Special thanks are due to Linda Rydberg and Priya Patel for their cheerful and competent support at the different stages of this report. We would also like to thank Beena Varghese for her inputs to the report. ii Members Rebecca Cook
... The middle classes have fared better than the poor, for whom there has been either no positive effect or a negative effect, especially in the poorest countries and the poorest social strata in all countries, including rich countries [30]. Women have fared worse, especially where out-of-pocket payments are required [31], where health insurance is based on formal employment or charged according to categories of risk (of which pregnancy is considered one), and where cuts in services have meant that more home care for family members is needed. In short, public health, equity and social justice all seem to have been sacrificed for other more questionable values, leaving the poorest and most vulnerable no better off than before. ...
... Intersectionality was a transversal theme in this review. It showed that women with disabilities, with less education or living in poorer households face additional challenges in benefitting from free healthcare policies [72]. Even in a context of free healthcare, these groups need more resources (money, information, disability-friendly transportation and facilities, etc.) to access healthcare services, and they are more prone to experience disrespect and abuse, rooted in prejudicial social norms. ...
Background: Over the past decade, an increasing number of low-and middle-income countries have reduced or removed user fees for pregnant women and/or children under five as a strategy to achieve universal health coverage. Despite the large number of studies (including meta-analyses and systematic reviews) that have shown this strategy's positive effects impact on health-related indicators, the repercussions on women's empowerment or gender equality has been overlooked in the literature. The aim of this study is to systematically review the evidence on the association between user fee policies in low-and middle-income countries and women's empowerment.
Methods: A systematic scoping review was conducted. Two reviewers conducted the database search in six health-focused databases (Pubmed, CAB Abstracts, Embase, Medline, Global Health, EBM Reviews) using English key words. The database search was conducted on February 20, 2020, with no publication date limitation. Qualitative analysis of the included articles was conducted using a thematic analysis approach. The material was organized based on the Gender at Work analytical framework.
Results: Out of the 206 initial records, nine articles were included in the review. The study settings include three low-income countries (Burkina Faso, Mali, Sierra Leone) and two lower-middle countries (Kenya, India). Four of them examine a direct association between user fee policies and women's empowerment, while the others address this issue indirectly-mostly by examining gender equality or women's decision-making in the context of free healthcare. The evidence suggests that user fee removal contributes to improving women's capability to make health decisions through different mechanisms, but that the impact is limited. In the context of free healthcare, women's healthcare decision-making power remains undermined because of social norms that are prevalent in the household, the community and the healthcare centers. In addition, women continue to endure limited access to and control over resources (mainly education, information and economic resources).
Conclusion: User fee removal policies alone are not enough to improve women's healthcare decision-making power. Comprehensive and multi-sectoral approaches are needed to bring sustainable change regarding women's empowerment. A focus on "gender equitable access to healthcare" is needed to reconcile women's empowerment and the efforts to achieve universal health coverage.
... Certains auteurs pensent que la budgétisation sensible au genre a un impact sur la croissance, ce qui permet de combler lesécarts inefficaces en matière de participation, d'éducation et de santé sur le marché du travail (King et Hill, 1995;Dollar et Gatti, 1999;Klasen, 2002;Knowles et al., 2002;Berik et al., 2009;Klasen et Lamanna, 2009). sensible au genre au niveau des dépenses (Chakraborty, 2016;Stotsky et Al., 2016;Khera, 2016;Das et al., 2015;Chakraborty et al., 2017;Demery et al., 1995;Kaur et Misra, 2003;Joshi, 2013) comme au niveau des recettes publiques (Feenberg et Rosen, 1995;Stotsky et Al., 2019;Sahn et Younger, 2003;Nanda, 2002;Daniels, 2005, Chakraborty, 2019. La plupart de ces auteurs n'utilisent pas des indices composites comme mesure des inégalités de genre. ...
Le but de cette étude est d'apprécier les effets de la budgétisation sexospécifique sur les inégalités de genre et sur les dépenses publiques en Afrique Subsaharienne. Pour atteindre cet objectif nous avons eu recours à une double approche méthodologique : une approche descriptive et une approché économétrique. L'approche économétrique est basée sur la méthode des moments généralisés en différence et en système (MMG). Contrairement aux études déjà réalisées sur la thématique, nous utilisons deux indices composites comme mesure des inégalités de genre et nous faisons en plus une analyse par blocs sous-régionaux. L'analyse porte sur un échantillon de 30 pays d'Afrique subsaharienne et couvre la période 2000-2015. Les résultats obtenus à l'aide d'une analyse en données de panel montrent que la budgétisation sexospécifique réduit significativement les inégalités de genre dans tous les blocs sous régionaux. Par ailleurs elle a un effet significatif sur les dépenses d'éducation en Afrique de l'Est et Afrique de l'Ouest.
... In light of the results, one complementary strategy to the existent measures could be to better address gender inequalities through empowerment-based interventions, since women are still less likely to utilise healthcare services due to limited decision-making power [56]. To radically improve women's capability to make health decisions, governments will have to go beyond mere reforms within the healthcare sector and introduce social and economic policies that strengthen women's positions in society as a whole [57]. ...
Background: A component of the performance-based financing intervention implemented in Burkina Faso was to provide free access to healthcare via the distribution of user fee exemption cards to previously identified ultra-poor. This study examines the factors that led to the receipt of user fee exemption cards, and the effect of card possession on the utilisation of healthcare services. Methods: A panel data set of 1652 randomly selected ultra-poor individuals was used. Logistic regression was applied on the end line data to identify factors associated with the receipt of user fee exemption cards. Random-effects modelling was applied to the panel data to determine the effect of the card possession on healthcare service utilisation among those who reported an illness six months before the surveys. Results: Out of the ultra-poor surveyed in 2017, 75.51% received exemption cards. Basic literacy (p = 0.03), living within 5 km from a healthcare centre (p = 0.02) and being resident in Diébougou or Gourcy (p = 0.00) were positively associated with card possession. Card possession did not increase health service utilisation (β = -0.07; 95% CI = -0.45; 0.32; p = 0.73). Conclusion: A better intervention design and implementation is required. Complementing demand-side strategies could guide the ultra-poor in overcoming all barriers to healthcare access.
... Supplyside determinants include the availability of healthcare providers, staff training, and medical supplies [7][8][9][10][11]. Demand-side determinants include cost, household wealth levels, maternal education, previous experience of obstetric complications, previous experiences at health care facilities, physical access to healthcare facilities, infectious disease testing, and cultural beliefs on pregnancy [9][10][11][12][13][14][15][16]. In western Kenya, monitoring fetal position, offering vaccinations, and providing medications were found to be major facilitators for ANC visits while clinic staff's negative attitudes and behaviors, long waiting times for services, and cost were identified as barriers [13]. ...
Background:
Antenatal care (ANC) and delivery by skilled providers have been well recognized as effective strategies to prevent maternal and neonatal mortality. ANC and delivery services at health facilities, however, have been underutilized in Kenya. One potential strategy to increase the demand for ANC services is to provide health interventions as incentives for pregnant women. In 2013, an integrated ANC program was implemented in western Kenya to promote ANC visits by addressing both supply- and demand-side factors. Supply-side interventions included nurse training and supplies for obstetric emergencies and neonatal resuscitation. Demand-side interventions included SMS text messages with appointment reminders and educational contents, group education sessions, and vouchers to purchase health products.
Methods:
To explore pregnant mothers' experiences with the intervention, ANC visits, and delivery, we conducted focus group discussions (FGDs) at pre- and post-intervention. A total of 19 FGDs were held with pregnant mothers, nurses, and community health workers (CHWs) during the two assessment periods. We performed thematic analyses to highlight study participants' perceptions and experiences.
Results:
FGD data revealed that pregnant women perceived the risks of home-based delivery, recognized the benefits of facility-based delivery, and were motivated by the incentives to seek care despite barriers to care that included poverty, lack of transport, and poor treatment by nurses. Nurses also perceived the value of incentives to attract women to care but described obstacles to providing health care such as overwork, low pay, inadequate supplies and equipment, and insufficient staff. CHWs identified the utility and limitations of text messages for health education.
Conclusions:
Future interventions should ensure that adequate workforce, training, and supplies are in place to respond to increased demand for maternal and child health services stimulated by incentive programs.
... Supply-side determinants include the availability of healthcare providers, staff training, and medical supplies [7][8][9][10][11]. Demand-side determinants include cost, household wealth levels, maternal education, previous experience of obstetric complications, previous experiences at health care facilities, physical access to healthcare facilities, infectious disease testing, and cultural beliefs on pregnancy [9][10][11][12][13][14][15][16]. In western Kenya, monitoring fetal position, offering vaccinations, and providing medications were found to be major facilitators for ANC visits while clinic staff's negative attitudes and behaviors, long waiting times for services, and cost were identi ed as barriers [13]. ...
Background: Antenatal care (ANC) and delivery by skilled providers have been well recognized as effective strategies to prevent maternal and neonatal mortality. ANC and delivery services at health facilities, however, have been underutilized in Kenya. One potential strategy to increase the demand for ANC services is to provide health interventions as incentives for pregnant women. In 2013, an integrated ANC program was implemented in western Kenya to promote ANC visits by addressing both supply- and demand-side factors. Supply-side interventions included nurse training and supplies for obstetric emergencies and neonatal resuscitation. Demand-side interventions included SMS text messages with appointment reminders and educational contents, group education sessions, and vouchers to purchase health products.
Methods: To explore pregnant mothers’ experiences with the intervention, ANC visits, and delivery, we conducted focus group discussions (FGDs) at pre- and post-intervention. A total of 19 FGDs were held with pregnant mothers, nurses, and community health workers (CHWs) during the two assessment periods. We performed thematic analyses to highlight study participants’ perceptions and experiences.
Results: FGD data revealed that pregnant women perceived the risks of home-based delivery, recognized the benefits of facility-based delivery, and were motivated by the incentives to seek care despite barriers to care that included poverty, lack of transport, and poor treatment by nurses. Nurses also perceived the value of incentives to attract women to care but described obstacles to providing health care such as overwork, low pay, inadequate supplies and equipment, and insufficient staff. CHWs identified the utility and limitations of text messages for health education.
Conclusions: Future interventions should ensure that adequate workforce, training, and supplies are in place to respond to increased demand for maternal and child health services stimulated by incentive programs.
... Supply-side determinants include the availability of healthcare providers, staff training, and medical supplies [7][8][9][10][11]. Demand-side determinants include cost, household wealth levels, maternal education, previous experience of obstetric complications, previous experiences at health care facilities, physical access to healthcare facilities, infectious disease testing, and cultural beliefs on pregnancy [9][10][11][12][13][14][15][16]. In western Kenya, monitoring fetal position, offering vaccinations, and providing medications were found to be major facilitators for ANC visits while clinic staff's negative attitudes and behaviors, long waiting times for services, and cost were identi ed as barriers [13]. ...
Background : Antenatal care (ANC) and delivery by skilled providers have been well recognized as effective strategies to prevent maternal and neonatal mortality. ANC and delivery services at health facilities, however, have been underutilized in Kenya. One potential strategy to increase the demand for ANC services is to provide health interventions as incentives for pregnant women. In 2013, an integrated ANC program was implemented in western Kenya to promote ANC visits by addressing both supply- and demand-side factors. Supply-side interventions included nurse training and supplies for obstetric emergencies and neonatal resuscitation. Demand-side interventions included SMS text messages with appointment reminders and educational contents, group education sessions, and vouchers to purchase health products.
Methods : To explore pregnant mothers’ experiences with the intervention, ANC visits, and delivery, we conducted focus group discussions (FGDs) at pre- and post-intervention. A total of 19 FGDs were held with pregnant mothers, nurses, and community health workers (CHWs) during the two assessment periods. We performed thematic analyses to highlight study participants’ perceptions and experiences.
Results : FGD data revealed that pregnant women perceived the risks of home-based delivery, recognized the benefits of facility-based delivery, and were motivated by the incentives to seek care despite barriers to care that included poverty, lack of transport, and poor treatment by nurses. Nurses also perceived the value of incentives to attract women to care but described obstacles to providing health care such as overwork, low pay, inadequate supplies and equipment, and insufficient staff. CHWs identified the utility and limitations of text messages for health education.
Conclusions : Future interventions should ensure that adequate workforce, training, and supplies are in place to respond to increased demand for maternal and child health services stimulated by incentive programs.
... Supply-side determinants include the availability of healthcare providers, staff training, and medical supplies [7][8][9][10][11]. Demand-side determinants include cost, household wealth levels, maternal education, previous experience of obstetric complications, previous experiences at health care facilities, physical access to healthcare facilities, infectious disease testing, and cultural beliefs on pregnancy [9][10][11][12][13][14][15][16]. In western Kenya, monitoring fetal position, offering vaccinations, and providing medications were found to be major facilitators for ANC visits while clinic staff's negative attitudes and behaviors, long waiting times for services, and cost were identi ed as barriers [13]. ...
Background : Antenatal care (ANC) and delivery by skilled providers have been well recognized as effective strategies to prevent maternal and neonatal mortality. ANC and delivery services at health facilities, however, have been underutilized in Kenya. One potential strategy to increase the demand for ANC services is to provide health interventions as incentives for pregnant women. In 2013, an integrated ANC program was implemented in western Kenya to promote ANC visits by addressing both supply- and demand-side factors. Supply-side interventions included nurse training and supplies for obstetric emergencies and neonatal resuscitation. Demand-side interventions included SMS text messages with appointment reminders and educational contents, group education sessions, and vouchers to purchase health products. Methods : To explore pregnant mothers’ experiences with the intervention, ANC visits, and delivery, we conducted focus group discussions (FGDs) at pre- and post-intervention. A total of 19 FGDs were held with pregnant mothers, nurses, and community health workers (CHWs) during the two assessment periods. We performed thematic analyses to highlight study participants’ perceptions and experiences. Results : FGD data revealed that pregnant women perceived the risks of home-based delivery, recognized the benefits of facility-based delivery, and were motivated by the incentives to seek care despite barriers to care that included poverty, lack of transport, and poor treatment by nurses. Nurses also perceived the value of incentives to attract women to care but described obstacles to providing health care such as overwork, low pay, inadequate supplies and equipment, and insufficient staff. CHWs identified the utility and limitations of text messages for health education. Conclusions : Future interventions should ensure that adequate workforce, training, and supplies are in place to respond to increased demand for maternal and child health services stimulated by incentive programs.
... Direct payments, which refer to fees levied for consultations with health professionals, are a major cause of this situation across the continent [1]. For example, studies have shown that direct payments for care provide limited access to care for the poor and women [6][7][8]. e continent has been undergoing transitions in various areas, such as demography, economy, and societal makeup that have resulted in new health expectations [1,2]. ...
Background:
To achieve the universal health coverage among other Sustainable Development Goals, African countries have shown the commitment by implementing strategies to improve access and coverage of health care services whose access is still very low. The achievement of universal health care requires the provision and availability of an adequate financing system. This study explored the wealth-related association of compulsory health insurance on maternal health care utilization in Gabon.
Methods:
The study used the 6th round of Gabon Demographic and Health Surveys (GDHSs)-2012 data to explore three outcome measures of maternal health care utilization extracted on number of antenatal care (ANC) visits during pregnancy, place of birth delivery, and postnatal health care. The dependent variable was women with health insurance coverage against those without. Logistic regression and propensity scoring matching analysed associations of health insurance coverage on women's utilization of health care.
Results:
Mean (+/- SD) age of women respondents of reproductive age was 29 years (9.9). The proportion of at least 4 antenatal care visits was 69.2%, facility-based delivery was 84.7%, and postnatal care utilization was 67.9%. The analysis of data showed disparities in maternal health care services utilization. The GDHS showed maternal age, and geographical region was significantly associated with maternal health care service utilization. A high proportion of urban dwellers and Christian women used maternal health care services. According to the wealth index, maternal health services utilization was higher in women from wealthy households compared to lower households wealth index (ANC (Conc. Index = 0.117; p ≤ 0.001), facility-based delivery (Conc. Index = 0.069; p ≤ 0.001), and postnatal care (Conc. Index = 0.075; p ≤ 0.001), respectively). With regard to health care insurance coverage, women with health insurance were more likely to use ANC and facility-based delivery services than those without (concentration indices for ANC and facility-based delivery were statistically significant; ANC: z-stat = 2.69; p=0.007; Conc. Index: 0.125 vs. 0.096 and facility-based delivery: z-stat = 3.38; p=0.001; Conc. Index: 0.076 vs. 0.053, respectively).
Conclusion:
Women enrollment in health insurance and improved household's financial status can improve key maternal health services utilization.
... It is well documented that men are less likely to seek help from health professionals especially in the absence of physical symptoms [14] . In Africa, despite the interference of social and physical barriers to women's access to healthcare services, women continue to seek health care more often than men [15] . Regarding infertility issues, men may raise arguments such as previous conceptions with other women, in an attempt to absolve them from having male fertility problems. ...
This study aimed to explore contestations within infertile couples seeking infertility therapy in a sub-Saharan society. Their views regarding infertility treatment were explored, including their arguments for or against different treatment options. The effects of the contributions of the various partners were analyzed. Semistructured in-depth interviews were conducted with people seeking infertility treatment at 3 different fertility clinics in Accra, Ghana. Participants were restricted to 45 persons from married heterosexual couples, with 15 respondents (5 male and 10 female) from each setting. Respondents were asked questions relating to the decision-making process toward seeking treatment and the reactions of their partners. Contestations tended to relate to 5 main themes: the cause of the infertility and who was to blame; male apathy; reluctance to provide semen samples for evaluation; an absentee husband due to work pressure; and finance relating to the cost of infertility treatment. This is the first study to highlight the contestations that arise between couples regarding their decision-making about alleviating their infertility via 3 different types of fertility clinics in Accra, Ghana. It is apparent that globalization and changing norms of family life have to a large extent, accounted for the changing ideas and practices surrounding infertility in urban Ghana.
... Only 49% of births are attended by skilled health personnel compared to the global average of 70% (3,4). Relative to financial risk protection, direct payments have been identified as a major cause of this situation across the continent, with several studies showing that direct payments of care provide limited access to care for the underprivileged and women (5)(6)(7). ...
Background: Universal Health Coverage (UHC) is achieved in a health system when all residents of a country are able to obtain access to adequate healthcare and financial protection. Achieving this goal requires adequate healthcare and healthcare financing systems that ensure financial access to adequate care. In Africa, accessibility and coverage of essential health services are very low. Many African countries have therefore initiated reforms of their health systems to achieve universal health coverage and are advanced in this goal. The aim of this paper is to examine the effects of UHC on equitable access to care in Africa.
Methods: A systematic review guided by the Cochrane Handbook was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria (PRISMA). Studies were eligible for inclusion if 1- they clearly mention studying the effect of UHC on equitable access to care, and 2- they mention facilitating factors and barriers to access to care for vulnerable populations. To be included, studies had to be in English or French. In accordance with PRISMA guidelines, our systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on April 24, 2018 (registration number CRD42018092793).
Results: In all 271 citations reviewed, 12 studies were eligible for inclusion. Although universal health coverage seems to increase the use of health services, shortages in human resources and medical supplies, socio-cultural barriers, physical inaccessibility, lack of education and information, decision-making power, and gender-based autonomy, prenatal visits, previous experiences, and fear of cesarean delivery were still found to deter access to, and use of, health services.
Discussion: Barriers to greater effectiveness of the UHC correspond to various non-financial barriers. There are no specific recommendations for these kinds of barriers. Generally, it is important for each country to research and identify contextual uncertainties in each of the communities of the territory. Afterwards, it will be necessary to put in place adapted strategies to correct these uncertainties, and thus to work toward a more efficient system of UHC, resulting in positive impacts on health outcomes.
... Binary logistic regression in Chapter 5 modelled the effects of selected independent variables on whether or not a recently ill/injured participant (n = 239) sought health care. I selected the independent variables from a literature review of barriers and determinants of care (Addai 2000, Nanda 2002, Ensor and Cooper 2004 and from participant-reported factors in the survey and in-depth interviews (e.g., money earned on a bad day, taking time away from work, no translator at the health facility). ...
This thesis contributes to understanding female migration and health in Ghana at the national and sub-national levels. It presents the first detailed comparative analyses of female migration using data from Ghana’s Population and Housing Censuses (2000−2010) and exploits these data to understand the gendered dimensions of migration in Ghana. This thesis then presents primary analyses from mixed-methods fieldwork to examine health and migration at the sub-national level among female migrants who work in the informal sector as market porters (kayayei). Primary data on migrant kayayei in Accra were collected using respondent driven sampling in an attempt to overcome challenges reported by other researchers surveying kayayei. Analyses of survey data (n = 625) and in-depth interviews (n = 48) examine the usefulness of respondent driven sampling in sampling migrants and assess health insurance and careseeking behaviours among recently ill/injured migrant kayayei. The findings in this thesis highlight that working-age migration is particularly pronounced in 2010, reinforcing economic opportunity as a likely driver of migration for both sexes. Census data identify one in three Ghanaian girls and women as internal migrants. Capturing data on highly mobile, vulnerable migrant populations can be difficult. Respondent driven sampling is not a one-size-fits-all solution for sampling hard-to-reach migrants in low- and middle-income countries, although respondent driven sampling produced the most comprehensive data set on migrant kayayei to date. These data show that access to formal health care in Accra remains largely inaccessible to kayayei migrants who suffer from greater illness/injury than the general female population in Accra and who are hindered in their ability to receive insurance exemptions. Too often, the lack of data on female migration reinforces the out-dated stereotype that girls and women do not participate in migration. The analyses in this thesis refute this stereotype and challenge historical assumptions that underestimated female migration. With internal migration on the rise in many settings, including Ghana, health systems must better recognise and respond to the varied needs of populations in multi-ethnic and multilingual countries to ensure that internal migrants can access affordable, quality health services across domestic borders.
... In disaggregating health coverage data, one group which is often shown to be disadvantaged are women, who through their life-cycle often have greater healthcare needs than men but who, due to economic inequalities, often have a lower ability to pay for services (World Health Organization 2016). According to the definition of UHC, many women ought to be the beneficiaries of cross-subsidies from more privileged groups in society in accessing health services, but this is clearly not happening at sufficient scale (Nanda 2002;Oxfam 2013). ...
In a webinar in 2015 on health financing and gender, the question was raised why we need to focus on gender, given that a well-functioning system moving towards Universal Health Coverage (UHC) will automatically be equitable and gender balanced. This article provides a reflection on this question from a panel of health financing and gender experts.
We trace the evidence of how health-financing reforms have impacted gender and health access through a general literature review and a more detailed case-study of India. We find that unless explicit attention is paid to gender and its intersectionality with other social stratifications, through explicit protection and careful linking of benefits to needs of target populations (e.g. poor women, unemployed men, female-headed households), movement towards UHC can fail to achieve gender balance or improve equity, and may even exacerbate gender inequity. Political trade-offs are made on the road to UHC and the needs of less powerful groups, which can include women and children, are not necessarily given priority.
We identify the need for closer collaboration between health economists and gender experts, and highlight a number of research gaps in this field which should be addressed. While some aspects of cost sharing and some analysis of expenditure on maternal and child health have been analysed from a gender perspective, there is a much richer set of research questions to be explored to guide policy making. Given the political nature of UHC decisions, political economy as well as technical research should be prioritized.
We conclude that countries should adopt an equitable approach towards achieving UHC and, therefore, prioritize high-need groups and those requiring additional financial protection, in particular women and children. This constitutes the ‘progressive universalism’ advocated for by the 2013 Lancet Commission on Investing in Health.
... Ces discriminations touchent notamment les plus pauvres (Assemblée générale des Nations Unies 2012), les minorités ethniques (OMS 2010), mais également les femmes, les personnes malades ou invalides, et les chômeurs (Bureau international du travail 2012). Dans certains contextes, le fait de payer les soins au point de service contribue également à renforcer des discriminations d'ordre socio-culturel, notamment liées au genre (Global Health Watch 2005;Nanda 2002). Qu'il s'agisse de la priorité de soins accordée aux hommes du ménage (OMS 2010) ou de la nécessité d'obtenir l'autorisation du chef de famille pour tout recours aux soins impliquant une dépense financière (Samb 2014), les femmes souffrent particulièrement de ces discriminations. ...
RÉSUMÉ
La couverture sanitaire universelle fait l’unanimité sur la scène internationale. On y voit l’expression d’un souci partagé de contribuer au droit à la santé par la réalisation du droit aux soins. Néanmoins, des tensions persistent entre la volonté affichée des acteurs de la santé mondiale, dont les discours utilisent souvent un référentiel associé à l’approche fondée sur les droits, et les rares moyens d’action qu’ils se donnent. En outre, la disposition de ces acteurs à réaliser effectivement ce droit est discutable. Cet article met en lumière ces tensions grâce à une analyse ancrée dans l’approche fondée sur les droits.
... Like direct taxes, fees can be personalized (different people are charged different amounts). Nanda (2002) examines the use of user fees in terms of its effect on women's utilization of health services in Africa and finds that these fees discourage use. Hillman and Jenlcner (2004) suggest, however, that it is also essential to assess the purposes for which these fees are used. ...
... The burden of paying for care, or for essential commodities such as gloves, can be an enormous obstacle for poor mothers who are already at increased risk of adverse outcomes. [19][20][21] In this study, mothers noted that the prices they were charged varied and likened them to bribery. To reduce the barrier of cost of care, the Government of Kenya recently established a policy that delivery services will be delivered free of charge, 22 but a subsequent newspaper article reported that some facilities were not experiencing an increase in deliveries in response to the policy, largely for reasons noted above by women in this study. ...
A qualitative inquiry was used to assess if incentives consisting of a hygiene kit, protein-fortified flour, and delivery kit reduced barriers to antenatal care and delivery services in Nyanza Province, Kenya. We conducted 40 interviews (baseline: five nurses, six mothers, one focus group of five mothers; follow-up: nine nurses, 19 mothers) to assess perceptions of these services. Mothers and nurses identified poor quality of care, fear of HIV diagnosis and stigma, inadequate transport, and cost of care as barriers. Nurses believed incentives encouraged women to use services; mothers described wanting good birth outcomes as their motivation. While barriers to care did not change during the study, incentives may have increased service use. These findings suggest that structural improvements-upgraded infrastructure, adequate staffing, improved treatment of women by nurses, low or no-cost services, and provision of transport-could increase satisfaction with and use of services, improving maternal and infant health.
... All facilities included in the study were found to serve a diverse range of patients including long-term residents, recent arrivals, internal and cross-border migrants. Women account for the majority of public healthcare users surveyed, illustrating the known gendered dimension of healthcare seeking-and associated gendered burden of healthcare-associated challenges-documented elsewhere [23][24][25]. Recent arrivals were significantly younger than longer-term residents, in line with existing literatureincluding in South Africa [21]. ...
South Africa’s public healthcare system responses seldom engage with migration. Our exploratory
study investigates migration proles and experiences of primary healthcare (PHC) users. A cross-sectional survey involving non-probability sampling was conducted with 229 PHC users at six purposively selected PHC clinics in three districts of SA. The survey captured socio-demographic information, migration histories, and PHC experiences. Chi square and Fischer’s exact tests were used to compare categorical variables, whilst Mann–Whitney U tests compared continuous variables between groups. Most PHC users were migrants (22% internal South African; 45% cross-border) who generally move for reasons other than healthcare seeking. Length of time accessing services at a specic clinic was shown to be key in describing experiences of PHC use. Understanding population movement is central to PHC strengthening in SA and requires improved understanding of mobility dynamics in regard to not just nationality, but also internal mobility and length of stay.
... Where insurance schemes exist, maternal health care needs to be included in the benefits package, and careful design is needed to ensure uptake by the poorest people (Borghi et al., 2006). Studies from African countries show that even though many poor women may be exempt from fees, there is little incentive for providers to apply exemptions, as they too are constrained by restrictive economic and health service conditions (Nanda, 2002). ...
India is presently undergoing a rapid demographic transition and experiencing a gradual increase in an ageing population. As a result, the households were continuously exposed to catastrophic economic impacts, ultimately influencing the healthcare utilisation of older people. The study examined the gender differentials in the choice of in-patient private and public hospitalisation among Indian elderly using Ander-sen's Health Behaviour Model. The database was acquired from the nationally representative cross-sectional survey (NSSO, 2017-18). Bivariate chi-square and binomial logistic regression techniques were used to fulfill the objective. In addition, the poor-rich ratio and concentration index was used to understand the inherent socioeconomic inequalities in healthcare preferences. The findings suggest that aged men were 27 percent more prone to avail private healthcare facilities than aged women. Further, older adults, who are married, belong to the upper caste, have higher education and gone through surgery, and primarily reside in an affluent society were more likely to prefer private in-patient hospitalisation. It represents negligence of older women in access to better healthcare who had financial strain and economically dependent. The study can be used to reframe existing public health policies and programs, particularly focusing on the older women, to avail cost-effective treatment.
The aim of this study is to verify the impact of gender budgeting on gender inequalities and on public spending in Sub-Saharan Africa. The analysis covers a sample of thirty (30) countries in Sub-Saharan Africa covering the period 2000–2015. The results obtained using a panel data analysis by the generalized method of moments (GMM) in difference and in system show that gender budgeting significantly reduces gender inequalities in Sub-Saharan Africa.
JEL CLASSIFICATION: H00; I00; J16
This study aims to comprehend nuances of gender barriers to access cataract surgery in the rural population of Gurugram district, Haryana, India. Data from 100 male and 100 female cataract surgery patients who underwent surgery at the university-affiliated hospital’s department of ophthalmology were examined. Data on the patients’ ages, the better eye’s and operated eye’s visual acuity, the cataract’s maturity at the time of surgery and the type of cataract surgery chosen were examined. Visual impairment was defined when the better eye’s visual acuity was less than 6/18 (0.32). At the time of surgery, women had a serious visual impairment in the better eye and also opted for a less expensive surgery option. In-depth interviews and focus group discussions were planned to understand the attitude, social norms and nuances of women’s accessibility to cataract surgery. This essay includes a qualitative investigation on access restrictions based on gender.
The goal of this study is to determine whether the female gender is a barrier for the access to cataract surgery in the rural population of Gurugram district, Haryana, India.
The data of consecutive 100 male and 100 female patients operated for cataract surgery at Department of Ophthalmology, University-affiliated hospital were studied. Data pertaining to age of the patients, visual acuity of the operated and better eye, maturity of the cataract at time of surgery, type of cataract surgery opted were analysed. Visual impairment was considered when visual acuity of the better eye was less than 6/18 (0.32).Two types of cataract surgery were offered to the patients: manual small-incision cataract surgery (SICS) and phacoemulsification. Independent t-tailed test was used to analyse data to ascertain female gender as a barrier to access cataract surgery.
The findings indicate that the difference in age at the time of surgery between men and women was not statistically significant ( p = .327). The analysis of visual impairment in the operated eye of men and women was also not statistically significant ( p = .173). However, the analysis of visual impairment in the better eye was strongly suggestive of gender bias with statistically significant results ( p = .001). In total, 71% male and 56% female patients opted for phacoemulsification surgery, whereas 44% women and 29% men chose less-expensive manual SICS surgery.
The study indicates that females had severe visual impairment in the better eye at the time of surgery and also opted for a less-expensive option indicating less financial freedom and decision-making power.
Studies conducted in Nigeria have shown that health insurance coverage for maternal care improves maternal care utilization. However, no previous Nigerian study has explored the effects which the various maternal healthcare services, covered by health insurance policy, have on the particular maternal healthcare and others. This study utilized secondary data from the most recent National Demographic and Health Survey for Nigeria to examine the effects of health insurance enrolment on broad range of maternal healthcare services. The outcome variables were early antenatal care visits, a minimum of four antenatal care contacts, place of delivery and postnatal care for a child within two months of delivery. The key explanatory variables were the various maternal healthcare services covered by health insurance. Binary logistic regression was used to measure the determinants of the various maternal health outcomes while controlling for potentially confounding variables. Health insurance coverage rate among Nigerian women was 2.1% with significant social disparity. The findings from the multivariate logistic regression showed that health insurance for antenatal care significantly increases the chances to make early antenatal care contacts; a minimum of four antenatal care contacts and postnatal care for a child. Having health insurance coverage for delivery care is associated with higher odds for delivery in health facilities. Health insurance policy with cash benefits is associated with increased odds for the various maternal healthcare services. We suggest that more studies be conducted to assess the progress in maternal care utilization, facilitated through health insurance programme.
Aim
The study aimed to explore factors related to the initiation and utilization of focused antenatal care (FANC) in the Southern District of Mzimba, Malawi.
Methods
This study used an exploratory qualitative design. Total of 22 in-depth interviews with pregnant women and community midwife assistant was conducted from December 2015 to January 2016 in Mzimba. Thematic analysis approach was adopted to identify the facilitator and barriers factors of the FANC initiation and utilization.
Results
Facilitator factors of FANC initiation and utilization included seeking pregnancy confirmation, medical treatment for an existing health problem and the support by community health extension workers. Barriers included the additional cost to free FANC service, lack of essential equipment, unfriendly adolescent reproductive health service, and HIV stigma.
Conclusion
Early initiation of FANC relies on both woman's awareness and community support. Promoting the use of FANC should focus on creating an enabling environment, e.g., increasing investment of essential medical equipment, reducing additional costs of FANC services, eliminating the discrimination against adolescent pregnancy and people living with HIV, and strengthening health personnel's training.
Community-based health insurance (CBHI) has gained popularity in many low- and middle-income countries, partly as a policy response to calls for low-cost, pro-poor health financing solutions. In Africa, Rwanda has successfully implemented two types of CBHI systems since 2005, one of which with a flat rate premium (2005–10) and the other with a stratified premium (2011–present). Existing CBHI evaluations have, however, tended to ignore the potential distributional aspects of the household contributions made towards CBHI. In this paper, we investigate the pattern of socioeconomic inequality in CBHI household premium contributions in Rwanda within the implementation periods. We also assess gender differences in CBHI contributions. Using the 2010/11 and 2013/14 rounds of national survey data, we quantify the magnitude of inequality in CBHI payments, decompose the concentration index of inequality, calculate Kakwani indices and implement unconditional quantile regression decomposition to assess gender differences in CBHI expenditure. We find that the CBHI with stratified premiums is less regressive than CBHI with a flat rate premium system. Decomposition analysis indicates that income and CBHI stratification explain a large share of the inequality in CBHI payments. With respect to gender, female-headed households make lower contributions towards CBHI expenditure, compared with male-headed households. In terms of policy implications, the results suggest that there may be a need for increasing the premium bracket for the wealthier households, as well as for the provision of more subsidies to vulnerable households.
This field-based study evaluates the impact of free maternal healthcare services on the healthcare-seeking behaviour of 125 pregnant women in six villages of Uttar Pradesh. The 87 Muslim and 38 non-Muslim women participating in this project appreciated the antenatal and postnatal care processes on offer. Yet, various government efforts to encourage women to give birth in government hospitals to comply with international benchmarks on reduction of maternal mortality rates were unsuccessful. The study explores the various reasons for the strategic choices made by these rural women, who continue to favour home-based delivery. The findings raise policy implications about how state financing of maternal healthcare provisions in India is to be delivered, in the best possible manner, at local levels.
Rates of female incarceration have markedly increased since the global ascendance of neoliberalism. Drawing on quantitative prison census data and qualitative analysis of inmate interviews, this article asks: Are women rendered vulnerable by neoliberal policies more likely to be victimized by state agents when under their control? We interrogate this using the case of Paraguay – positing that paradigmatically neoliberal regimes systematically incarcerate the precarious, and enact physical and emotional violence against them during incarceration. Findings confirm this reality, with marginalized women disproportionately incarcerated, and disproportionately likely to be abused while in custody. This article advances knowledge about criminalization in neoliberal contexts.
Objectif: Cette recherche évalue l’impact des interventions de subvention du paiement des soins sur le pouvoir d’agir (empowerment) des membres des Comités de gestion (Coges) communautaires des services de santé et de leur organisation au Burkina Faso. Participants: La collecte des données s’est effectuée en 2010 dans huit centres de santé primaire pendant six mois auprès de 140 personnes. Lieu: Trois districts sanitaires du Burkina Faso (Dori, Sebba et Ouargaye). Intervention: Depuis 2006, le gouvernement subventionne 80 % des coûts des soins obstétricaux et néonataux d’urgence pour les femmes enceintes. Depuis 2008, une ONG prend en charge les 20 % restant et elle subventionne à 1 00 % les soins pour les enfants de moins de cinq ans à Dori et Sebba. De plus, une stratégie communautaire d’exemption du paiement pour les indigents a été organisée dans ces trois districts. Résultats: Les interventions ont renforcé le pouvoir d’agir des membres des Coges et de leur organisation. Cela se traduit par une plus grande capacité à s’impliquer dans la résolution des problèmes de santé de la communauté. L’intervention de l’ONG spécifiquement à Dori et Sebba fait que le renforcement du pouvoir d’agir y est plus grand qu’à Ouargaye. Conclusion: La subvention du paiement des soins au point de service est porteuse d’un fort potentiel de renforcement du pouvoir d’agir des membres des Coges et de leur organisation.
The new development framework aspires to merge long-term hopes for environmental, political and financial sustainability with international poverty eradication goals. Central to this agenda is the promotion and protection of the human rights of women and girls. Yet national mechanisms, donors and international development agencies often do not fully tackle these issues or confront the accompanying politically sensitive, complex issues intermingling religion, socioeconomic status, social, cultural and family life. The increasing reliance on private investment may further weaken a women’s rights approach. The proposed framework described in the High-Level Panel of Eminent Persons Report could further systematize this problem, even though it improves on the MDGs by expanding targets related to women. Success will require support for a potent mix of advocacy, movement building and a complex set of ground-based strategies that shift cultural practices, laws and policies that harm women and girls. Funding for advocacy and interventions that hold firm on human rights is imperative, but given the conflicting loyalties of governments and public–private partnerships, reliance on either sector may be risky. An analysis of the status of women’s rights work, infrastructure and donor support in Bangladesh and South Africa shows the need for vigilance and long-term investment in effective work.
Résumé
Le nouveau programme de développement aspire à fusionner des espoirs à long terme pour la viabilité environnementale, politique et financière avec les objectifs internationaux d’éradication de la pauvreté. La promotion et la protection des droits fondamentaux des femmes et des filles sont au centre de ce programme. Toutefois, les mécanismes nationaux, les donateurs et les institutions internationales du développement échouent souvent à pleinement ces questions ou se heurtent aux problèmes complexes et politiquement sensibles qui les accompagnent, mêlant la religion, le statut socio-économique, la vie sociale, culturelle et familiale. Le recours accru aux investissements privés risque d’affaiblir encore une approche des droits des femmes. Le programme proposé dans le rapport du Groupe de personnalités de haut niveau pourrait systématiser davantage ce problème, même s’il représente un progrès par rapport aux OMD en élargissant les cibles relatives aux femmes. Le succès exigera de soutenir une association puissante de plaidoyer, de renforcement des mouvements et d’un ensemble complexe de stratégies ancrées sur le terrain et propres à changer les pratiques culturelles, les lois et les politiques qui lèsent les femmes et les filles. Il est impératif de mobiliser un financement pour le plaidoyer et des interventions qui ne transigent pas sur les droits de l’homme. Mais, compte tenu des loyautés concurrentes des gouvernements et des partenariats publics-privés, il peut être risqué de se reposer sur ces deux acteurs. Une analyse de l’état du travail, de l’infrastructure et du soutien des donateurs en faveur des droits des femmes au Bangladesh et en Afrique du Sud montre qu’il faut être vigilants et investir à long terme dans des projets efficaces.
Resumen
El nuevo marco de desarrollo aspira a unir las esperanzas a largo plazo de sostenibilidad ambiental, política y financiera con los objetivos de erradicación de la pobreza internacional. Fundamental para esta agenda es la promoción y protección de los derechos humanos de las mujeres y niñas. Sin embargo, los mecanismos nacionales, donantes e instituciones de desarrollo internacional a menudo no abordan estos asuntos totalmente ni confrontan los complejos asuntos políticamente delicados entremezclados con religión, condición socioeconómica y la vida social, cultural y familiar. La creciente dependencia de la inversión privada podría debilitar aún más el enfoque en los derechos de las mujeres. El marco propuesto descrito en el Informe del Grupo de Alto Nivel de Personas Eminentes podría sistematizar aún más este problema, aunque mejora los ODM al ampliar las metas relacionadas con las mujeres. El éxito requerirá apoyo para una mezcla potente de actividades de promoción y defensa, movilización y una serie compleja de estrategias basadas en el terreno que cambien las prácticas culturales, leyes y políticas que perjudican a las mujeres y niñas. Es imperativo financiar las actividades de promoción y defensa y las intervenciones que reafirman los derechos humanos, pero debido al conflicto de lealtades de los gobiernos y alianzas entre los sectores público y privado, la dependencia de cualquiera de los dos sectores podría ser riesgosa. Un análisis del estado del trabajo relacionado con los derechos de las mujeres, la infraestructura y el apoyo de donantes en Bangladesh y Ãfrica meridional muestra la necesidad de vigilancia e inversión a largo plazo en trabajo eficaz.
Importance
Eye disease burden could help guide health policy making. Differences in cataract burden by sex is a major concern of reducing avoidable blindness caused by cataract.
Objective
To investigate the association of sex with the global burden of cataract by year, age, and socioeconomic status using disability-adjusted life-years (DALYs).
Design, Setting, and Participants
This international, comparative burden-of-disease study extracted the global, regional, and national sex-specific DALY numbers, crude DALY rates, and age-standardized DALY rates caused by cataract by year and age from the Global Burden of Disease Study 2015. The DALY data were collected from January 1, 1990, through December 31, 2015, for ever 5 years. The human development index (HDI) in 2015 was extracted as an indicator of national socioeconomic status from the Human Development Report.
Main Outcomes and Measures
Comparisons of sex-specific DALY estimates due to cataract by year, age, and socioeconomic status at the global level. Paired Wilcoxon signed rank test, Pearson correlation, and linear regression analyses were performed to evaluate the socioeconomic-associated sex differences in cataract burden.
Results
Differences in rates of cataract by sex were similar between 1990 and 2015, with age-standardized DALY rates of 54.5 among men vs 65.0 among women in 1990 and 52.3 among men vs 67.0 among women in 2015. Women had higher rates than men of the same age, and sexual differences increased with age. Paired Wilcoxon signed rank test revealed that age-standardized DALY rates among women were higher than those among men for each HDI-based country group (z range, −4.236 to −6.093; P < .001). The difference (female minus male) in age-standardized DALY rates (r = −0.610 [P < .001]; standardized β = −0.610 [P < .001]) and the female to male age-standardized DALY rate ratios (r = −0.180 [P = .02]; standardized β = −0.180 [P = .02]) were inversely correlated with HDI.
Conclusions and Relevance
Although global cataract health care is progressing, sexual differences in cataract burden showed little improvement in the past few decades. Worldwide, women have a higher cataract burden than men. Older age and lower socioeconomic status are associated with greater differences in rates of cataract by sex. Our findings may enhance public awareness of sexual differences in global cataract burden and emphasize the importance of making sex-sensitive health policy to manage global vision loss caused by cataract.
Concern about side effects is one of the most commonly cited reasons for women’s non-use of contraceptives in sub-Saharan Africa, and the most common reason why women discontinue family planning. While studies find that some of women’s worries about contraceptives are based on distressing side effects, such as menstrual disruption, nausea, weight gain and delays in fertility, researchers frequently focus on misinformation spread by rumour. These studies decontextualize women’s concerns from the larger gendered context of their lives. Drawing on ethnographic field research carried out in northern Ghana with a feminist approach to understanding reproduction, this chapter examines women’s concerns about side effects, and the impact of these concerns on family planning practice. I show that despite anxiety about side effects, and their real physical, social and economic consequences, some women’s conceptions of the action of contraceptives on their bodies are pragmatic. Ethnogynecological perceptions of the importance of blood matching, combined with the importance of having small families for economic success, often encourage contraceptive use and mitigate the action of side effects rather than prompt non-use or discontinuation.
Evaluation of free caesarean section in Benin
Introduction: The Benin Government introduced free caesarean section in public hospitals in 2009 and a national agency was created to manage free caesarean section.
Methods: Three years after introduction of free caesarean section, we evaluated this measure in the Ouidah hospital area (HZO) by analysing the hospital structure, the implementation process and the results.
Results: This study showed the efficacy of free caesarean section, which has helped to increase the caesarean rate from 2.38% in 2009 to 3.48% in 2012, a caesarean section mortality rate of 0.99%, insufficient information for beneficiaries, some drugs are not covered by this measure, and additional costs must be paid by beneficiaries.
Discussion: These results indicate the need for a detailed cost analysis to adjust the unit cost for caesarean section. This type of evaluation should be performed in all public hospitals in the country to more clearly identify malfunctions.
Tous les chapitres de cette nouvelle édition ont été écrits par des pédagogues, des enseignants universitaires et des formateurs rompus depuis de longues années à l’exercice du partage de connaissances en évaluation de programmes, tout en mettant l’accent sur la pratique plutôt que sur la théorie. Nous avons ajouté quatre nouveaux chapitres, car les connaissances en évaluation évoluent constamment, sur la stratégie de l’étude de cas, l’évaluation économique, les approches participatives ou encore l’approche dite réaliste. Il manquait dans la première édition des exemples relatifs à l’usage des méthodes mixtes, décrites dans la première partie. Deux nouveaux chapitres viennent donc combler cette lacune.
Un défi essentiel auquel fait face tout enseignant en évaluation est lié à la maîtrise de la grande diversité des approches évaluatives et des types d’évaluation. La seconde partie de l’ouvrage présente quelques études de cas choisies pour montrer clairement comment les concepts qui auront été exposés sont employés dans la pratique. Ces chapitres recouvrent plusieurs domaines disciplinaires et proposent divers exemples de pratiques évaluatives.
Gender budgeting is an approach to budgeting that uses fiscal policy and administration to promote gender equality and girls and women’s development. This paper posits that, properly designed, gender budgeting improves budgeting, and it places budgeting for this purpose in the context of sound budgeting principles and practices. The paper provides an overview of the policies and practices associated with gender budgeting as they have emerged across the world, as well as examples of the most prominent initiatives in every region of the world. Finally, it suggests what can be learned from these initiatives.
Since the introduction of user fee systems in the government health facilities of most African countries, which shifted part of the burden of financing health care onto the community, affordability of basic health care has been a much discussed topic. It is sometimes assumed that in areas where high levels of spending for traditional treatments are common, people would be able to pay for basic health care at governmental facilities, but may not be willing to do so. However, examining willingness to pay and ability to pay in the broader context of different types of illness and their treatment leads us to a very different conclusion. In the course of a medical-ethnographic study in south-eastern Tanzania, we found evidence that people may indeed be willing, but may nevertheless not be able, to pay for biomedical health care – even when they can afford costly traditional medicine. In this article, we suggest that the ability to pay for traditional treatment can differ from ability to pay for hospital attendance for two main reasons. First, many healers – in contrast to the hospital – offer alternatives to cash payments, such as compensation in kind or in work, or payment on a credit basis. Secondly, and more importantly, the activation of social networks for financial help is different for the two sectors. For the poor in particular, ability to pay for health care depends a great deal on contributions from relatives, neighbours and friends. The treatment of the ‘personalistic’ type of illness, which is carried out by a traditional healer, involves an extended kin-group, and there is high social pressure to comply with the requirements of the family elders, which may include providing financial support. In contrast, the costs for the treatment of ‘normal’ illnesses at the hospital are usually covered by the patient him/herself, or a small circle of relatives and friends.
In response to The Lancets April 14 editorial on structural adjustment and health in Africa it is surprising that the World Bank report did not include maternal mortality as a yardstick for monitoring health standards in Africa: maternal mortality seems to be a better index of social and economic development than perinatal or infant mortality. Obstetric performance was reviewed in parts of Nigeria after the introduction of the structural adjustment program (SAP). In the 1970s and early 1980s the Nigerian economy was buoyant thanks to petroleum exports but when oil prices slumped the government was forced to introduce SAP. As a result most of the costs that had been borne by the government were gradually passed on to individuals of all the sectors affected health seems to have been the hardest hit. Looking at factors that might have been responsible for the rising maternal mortality rate in the Zaria area of Northern Nigeria it was found that between 1983 and 1988 there had been no significant change in the numbers of obstetricians and obstetric residents at the Ahmadu Bello Teaching Hospital; there was a slight rise in the number of midwives. However the number of deliveries in 1988 was only 46% of the figure for 1983 and the proportion of obstetric admissions that were complicated more than tripled. Maternal deaths at the hospital numbered 48 per year in 1983-85 and 75 in 1988 an increase of 56%. These changes in obstetric indices may not be unrelated to financial policies in hospital care. In 1983 all aspects of maternity care at the hospital were free. In 1985 following the reduction in government subsidy fees were introduced for some services leading to a fall in the number of pregnant women attending the hospital. By 1988 patients were asked to pay for their treatment; with the mean interval between admission and surgery increasing significantly and contributing to the high maternal morbidity and mortality rates in Zaria. (Full text modified)
In many developing countries people are expected to contribute to the cost of health care from their own pockets. As a result, people's ability to pay (ATP) for health care, or the affordability of health care, has become a critical policy issue in developing countries, and a particularly urgent issue where households face combined user fee burdens from various essential service sectors such as health, education and water. Research and policy debates have focused on willingness to pay (WTP) for essential services, and have tended to assume that WTP is synonymous with ATP. This paper questions this assumption, and suggests that WTP may not reflect ATP. Households may persist in paying for care, but to mobilize resources they may sacrifice other basic needs such as food and education, with serious consequences for the household or individuals within it. The opportunity costs of payment make the payment 'unaffordable' because other basic needs are sacrificed. An approach to ATP founded on basic needs and the opportunity costs of payment strategies (including non-utilization) is therefore proposed. From the few studies available, common household responses to payment difficulties are identified, ranging from borrowing to more serious 'distress sales' of productive assets (e.g. land), delays to treatment and, ultimately, abandonment of treatment. Although these strategies may have a devastating impact on livelihoods and health, few studies have investigated them in any detail. In-depth longitudinal household studies are proposed to develop understanding of ATP and to inform policy initiative which might contribute to more affordable health care.
This paper reviews current literature and debates about Health Sector Reform (HSR) in developing countries in the context of its possible implications for women's health and for gender equity. It points out that gender is a significant marker of social and economic vulnerability which is manifest in inequalities of access to health care and in women's and men's different positioning as users and producers of health care. Any analysis of equity must therefore include a consideration of gender issues. Two main approaches to thinking about gender issues in health care are distinguished--a 'women's health' approach, and a 'gender inequality' approach. The framework developed by Cassels (1995), highlighting six main components of HSR, is used to try to pinpoint the implications of HSR in relation to both of these approaches. This review makes no claim to sociological or geographical comprehensiveness. It attempts instead to provide an analysis of the gender and women's health issues most likely to be associated with each of the major elements of HSR and to outline an agenda for further research. It points out that there is a severe paucity of information on the actual impact of HSR from a gender point of view and in relation to substantive forms of vulnerability (e.g. particular categories of women, specific age groups). The use of generic categories, such as 'the poor' or 'very poor', leads to insufficient disaggregation of the impact of changes in the terms on which health care is provided. This suggests the need for more carefully focused data collection and empirical research.
This paper reviews the experience of implementing user fees in Africa. It describes the two main approaches to implementing user fees that have been applied in African countries, the standard and the Bamako Initiative models, and their common objectives. It summarizes the evidence concerning the impact of fees on equity, efficiency and system sustainability (as opposed to financial sustainability), and the key bottlenecks to their effective implementation. On the basis of this evidence it then draws out three main sets of lessons, focusing on: where and when to implement fees; how to enhance the impact of fees on their objectives; and how to strengthen the process of implementation. If introduced by themselves, fees are unlikely to achieve equity, efficiency or sustainability objectives. They should, therefore, be seen as only one element in a broader health care financing package that should include some form of risk-sharing. This financing package is important in limiting the potential equity dangers clearly associated with fees. There is a greater potential role for fees within hospitals rather than primary facilities. Achievement of equity, efficiency and, in particular, sustainability will also require the implementation of complementary interventions to develop the skills, systems and mechanisms of accountability critical to ensure effective implementation. Finally, the process of policy development and implementation is itself an important influence over effective implementation.
We studied the cost and affordability of 'free' maternity services at government facilities in Dhaka, Bangladesh, to assess whether economic factors may contribute to low utilization. We conducted a questionnaire survey and in-depth interviews among 220 post-partum mothers and their husbands, selected from four government maternity facilities (three referral hospitals and one Mother and Child Health hospital) in Dhaka. Mothers with serious complications were excluded. Information was collected on the costs of maternity care, household income, the sources of finance used to cover the costs, and the family's willingness to pay for maternity services. The mean cost for normal delivery was 1275 taka (US$31.9) and for caesarean section 4703 taka (US$117.5). Average monthly household income was 4933 taka (US$123). Twenty-one per cent of families were spending 51-100% of monthly income, and 27% of families 2-8 times their monthly income for maternity care. Overall, 51% of the families (and 74% of those having a caesarean delivery) did not have enough money to pay; of these, 79% had to borrow from a money lender or relative. Surprisingly, 72% of the families said they were willing to pay a government-levied user charge, though this was less popular among low-income families (61%). 'Free' maternity care in Bangladesh involves considerable hidden costs which may be a major contributor to low utilization of maternity services, especially among low-income groups. To increase utilization of safer motherhood services, policy-makers might consider introducing fixed user charges with clear exemption guidelines, or greater subsidies for existing services, especially caesarean section.
This paper looks at what happened in Ghana following increases in government health service charges in 1983 and 1985. A combination of analysis of records, interviews and discussion with community groups was used.
Utilization in rural areas was affected drastically by the substantial increase of 1985. The effect on urban utilization was less extreme and less durable. The age composition of users changed. After the 1985 increase, proportionately more of the 15-45 age group used the government services—this was particularly at the expense of the over-45s. The population was obviously concerned with the cost of health care, but were even more concerned about the quality of care and receiving value-for-money. They were unwilling to pay if drug supplies were unreliable or staff behaved unpleasantly.
Some problems were encountered with implementing the policy of charges. Many facilities did not spend the revenue to which they were entitled—an interesting point, as the existence of the skill to spend money is often tacitly assumed!
Charges also had significant indirect resource consequences. Reduced utilization freed up staff time which should be used to provide other services, particularly preventive ones. This opportunity has not, as yet, been exploited.
Fee revenue can be dangerously attractive, particularly if it is administratively more accessible than general government allocations. There is a danger that revenue collection becomes a disproportionately important evaluative criterion in a system which is, after all, ultimately intended to improve health status.
In designing country health care programs to achieve the goals of the Alma Alta declaration of ‘Health for All’, developing countries have been confronted with the problem of increased health care needs and decreased available resources. Health economists have proferred several possible solutions to this fiscal shortfall, including cost-recovery measures through the imposition of user fees for curative services at government health facilities. Health care providers have been noticeably absent from discussions of the many possible implications of these fees; consequently, resultant programs and policies may be economically sound but may fail to place a sufficient emphasis on features designed to maintain and improve the health of the population.In the present paper we examine the possible impact of user fees on the health of individuals residing in Bangladesh, one potential candidate country for user fees. We note evidence that the existing government health care system appears already to be providing care to two of the most medically vulnerable groups in Bangladesh, the poor and women, and provide evidence that such fees may seriously interfere with maintaining this patient profile. We discuss the significant public health role that curative care provides for the individuals, their families and the wider community. We suggest that additional questions should be asked by health care providers, anthropologists and economists prior to institution of user fees in the government system and that such measures should first be introduced in an experimental format with a rigorous and comprehensive impact evaluation.
This paper reports on research undertaken for the Government of Tanzania to investigate the case for the introduction of user, charges in the health services. A parallel report is being completed on the potentiality of compulsory health insurance for those in regular employment. Five studies were undertaken at the national level. The main studies were interviews of nearly 900 outpatients at the main hospitals and interviews with over 1800 households all over the country with access to both government and mission hospitals. Information was collected on travel time, travel cost, and waiting time, which health facilities were chosen and why, the cost of using them, and difficulty in finding the money to pay and willingness to pay user charges.
The most important conclusion was that because of inadequate supples of drugs and of food at hospitals many patients had to incur substantial costs to use the ‘free’ services in addition to travel costs. It is therefore concluded that modest charges, with attempts to exempt the poor, would be less inequitable than the existing situation, if the revenue could be used to ensure that supplies were always adequate at government health services. The level of charges suggested was based on what the majority surveyed said they were willing to pay.
We investigated the impact of a short-lived policy of charging fees to patients attending public-sector outpatient health facilities in Kenya by collecting data on attendance at Nairobi's Special Treatment Clinic for sexually transmitted diseases (STDs) before (23 months), during (9 months), and after (15 months) the user-charge period. During the user-charge period, the seasonally adjusted total mean monthly attendance of men decreased significantly to 40% (95% CI 36-45) of that before fees were levied. Attendance rose in the post-user-charge period, but reached only 64% (59-68) of the pre-user-charge level. For women, the adjusted total mean monthly attendance during the user-charge period was reduced significantly to 65% (55-77) of the pre-user-charge level. Mean monthly attendance by women rose in the post-user-charge period to 22% (9-37) above the pre-user-charge level. There was no evidence of an increase in attendance over the course of the user-charge period among either men or women. The introduction of user fees probably increased the number of untreated STDs in the population, with potentially serious long-term health implications. The user-fee experience in Kenya should be carefully evaluated before similar measures are introduced elsewhere.
Following a nationwide increase in user fees for health services in Swaziland, this paper analyzes the effect of the fee increase on overall patient use of health services, on which types of services, curative vs preventive, were most affected, and on changes in utilization by higher paying and lower paying groups. Patient attendance data from a 71% sample of government and mission health facilities, suggests that the 'people are willing and able to pay for health services' assertion is not supported by the Swaziland case. Following the fee increase, average attendance decreased at government facilities by 32.4%, increased at mission facilities by 10.2%, leading to a combined decline of approx. 17%. Patient visits designed to protect against childhood diseases, BCG and DPT immunizations, or against dehydration in children, show average attendance declines of -16, -19, and -24%, respectively, while visits for musculoskeletal diseases, a less serious disease, declined 1.2%. The analysis also suggests that up to 34% of the overall decline in attendance was among patients who previously had paid the least for health care with part of this decline likely including fewer multiple visits.
Many developing countries, particularly in Africa, have recently introduced payment schemes based on the selling of essential drugs. This is one of the main elements of the Bamako Initiative according to which the income generated would ensure a reliable supply of drugs and would improve other aspects of the quality of the services offered. Thus, quality improvements would compensate for the financial barrier and as a result the utilization of public health services would be increased or at least maintained. These hypotheses have proven to be partially valid, since there have been cases where the utilization of health services has increased and others where it has decreased; these inconclusive results have fuelled criticisms concerning the inequitable nature of these measures.
World Bank/International Monetary Fund Structural Adjustment Programs (SAPs) have been introduced in over 40 countries of Africa. This article outlines their economic policy measures and the experience of the countries that have introduced them, in terms of nutrition, health status, and health services. The evidence indicates that SAPs have been associated with increasing food insecurity and undernutrition, rising ill-health, and decreasing access to health care in the two-thirds or more of the population of African countries that already lives below poverty levels. SAPs have also affected health policy, with loss of a proactive health policy framework, a widening gap between the affected communities and policy makers, and the replacement of the underlying principle of equity in and social responsibility for health care by a policy in which health is marketed commodity and access to health care becomes an individual responsibility. The author argues that there is a deep contradiction between SAPs and policies aimed at building the health of the population. Those in the health sector need to contribute to the development and advocacy of economic policies in which growth is based on human resource development, and to the development of a civic environment in Africa that can ensure the implementation of such policies.
Since the Bamako Initiative was launched in 1988, many African countries have embarked on comprehensive primary health care programs relying, at least partially, on revenues generated through user fees to revitalize health care delivery systems. Although these programs contain two critical components, user fees and improved quality, policy debates have tended to focus on the former and disregarded the latter. The purpose of this study is to provide a net assessment of these two components by testing how user fees and improved quality affect health facility utilization among the overall population and specifically among the poorest people.
Literature suggests that in theory, the efficiency of user charges for health services is related to the level of externality, the price elasticity of demand, the proportion of total costs which are private access costs, and the level of the government budget constraint. Theoretical models predict that price elasticity of demand for health services is likely to be higher for lower income groups and that user charges are therefore unlikely to promote equity, or reduce the discrepancies between the utilisation rates of the rich and poor, 'ceteris paribus'. Empirical evidence tends to confirm the latter prediction but to suggest that user charges in many countries provide the scope for welfare gains for the majority. Unfortunately, this scope is seldom exploited in practice. It is argued that many countries have little choice but to try to exploit the potential for majority gains, but that more emphasis should be placed on ensuring quality improvements than on superficial financial measures of success.
The authors examine the strategies rural households in Burkina Faso used to cope with the costs of illness in order to avert negative effects for household production and assets. They use information from 51 qualitative interviews, a household time allocation study and a household survey. Both surveys use the same sample of n = 566 households. The authors analyze these strategies along four dimensions: the type of behavior, the sequence in which strategies employed, the level at which strategies are negotiated, i.e. the household level, the non-household extended kin level or the community level, and finally the success of strategies in protecting household production and assets. A taxonomy of 11 distinct types of coping behavior is developed which have the effect of either avoiding costs by 'ignoring' disease, or of minimizing the impact of costs on the household once illness is perceived. Intra-household labor substitution was the main strategy to compensate for any labor lost to illness. However, labor substitution did not eliminate production losses in the majority of households struck with severe illness of a productive member. Only wealthy household were able to fully compensate labor losses by hiring labor or by investing in equipment to enhance productivity. Sales of livestock was the main strategy to cope with the financial costs of health care. None of the households studied fell into calamity. However, the households' ability to avert the loss of production and/or assets was very varied and depended on household size, composition and assets, on the type and duration of illness and on clustering of crises (e.g. several repetitive or simultaneous illnesses or concurrent seasonal stress). Coping with the costs of illness largely occurred at the level of the household. Inter-household transfers of resources played only a small role. The authors develop the concept of risk households and suggest several policies with the potential to strengthen the ability of households to cope with the economic costs of illness.
An international survey of health service user fee and exemption policies in 26 low- and middle-income countries assessed whether user fee policies were supported by measures that protect the poor. In particular, it explored whether governments were introducing a package of supportive measures to promote service improvements that benefit disadvantaged groups and tackle differential ability to pay through an effective series of exemptions. The results show that many countries lack policies that promote access for disadvantaged groups within user fee systems and quality improvements such as revenue retention at the health care facility and expenditure guidelines for local managers. More significant policy failures were identified for exemptions: 27 percent of countries had no policy to exempt the poor; in contrast, health workers were exempted in 50 percent of countries. Even when an official policy to exempt the poor existed, there were numerous informational, administrative, economic, and political constraints to effective implementation of these exemptions. The authors argue that user fee policy should be developed more cautiously and in a more informed environment. Fees are likely to exacerbate existing inequities in health care financing unless exemptions policy can effectively reach those unable to pay.
Utilisation of outpatient services in government owned district hospitals in Dar es Salaam, declined by more than 50% following the introduction of user charges in these health facilities in mid July 1993. Outpatient attendances in the private health facilities studied remained constant throughout the year although these charged higher fees. Education and employment status were found to be major factors influencing utilisation of public versus private health facilities. Public facility users (62.8%) had five to eight years of formal education. Private facility users with five to eight years of education were 45.5% and those with more than years of education were 47.1%. While 68.6% of public facility users paid for their own healthcare, more than a quarter (27.3%) had their costs met by relatives or friends. The employer paid for 72% of private facility users, 49.2% of whom stated that this was the reason why they used private facilities. Despite introduction of charges in public hospitals, availability of prescribed medication was poor. Drugs were reported to be always available by only 27.3% of public health facility users compared to 80% of private health facility users.
This paper reports the results of a study in Uganda of the ‘informal’ economic activities of health workers, defined as those which earn incomes but fall outside official duties and earnings. The study was carried out in 10 sub-hospital health facilities of varying size and intended role and used a variety of quantitative and qualitative methods. The paper focuses on those activities which are carried out inside public health facilities and which directly affect quality and accessibility of care. The main strategies in this category were the leakage of drug supply, the informal charging of patients and the mismanagement of revenues raised from the formal charging of patients. Few of the drugs supplied to health units were prescribed and issued in those sites. Most health workers who have the opportunity to do so, levy informal charges. Where formal charges are collected, high levels of leakage occur both at the point of collection and at higher levels of the system.
This paper constructs a model of saving for retired single people that includes heterogeneity in medical expenses and life expectancies, and bequest motives. We estimate the model using Assets and Health Dynamics of the Oldest Old data and the method of simulated moments. Out-of-pocket medical expenses rise quickly with age and permanent income. The risk of living long and requiring expensive medical care is a key driver of saving for many higher-income elderly. Social insurance programs such as Medicaid rationalize the low asset holdings of the poorest but also benefit the rich by insuring them against high medical expenses at the ends of their lives. (c) 2010 by The University of Chicago. All rights reserved..
Structural adjustment and health: a literature review of the debate, its role players and presented empirical evidence
- A Breman
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Household coping strategies in response to the introduction of user charges for social service: a case study on health in Uganda
- H Lucas
- Nuwagaba
Lucas H, Nuwagaba A. Household coping strategies in response to the introduction of user charges for social service: a case study on health in Uganda. IDS Working Paper 86. Brighton: Institute for Development Studies, 1999
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Health Financing: Designing and Implementing Pro-Poor Policies
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The hidden cost of ÔfreeÕ maternity care in Dhaka
- S Nahar
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User fees for health care: Waivers, exemptions and implementation issues
- R Bitran
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Quality of health care and its role in cost recovery with a focus on empirical findings about willingness to pay for quality improvements
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