HLTH 8052 Week 4 User Fee Removal Position Paper Example

Remove Primary Care Fees Only Once the Money Is Found: A Conditional Position on User Fees in a Low-Income Health System

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Walden University

HLTH 8052: Advanced Issues in Global Public Health

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Month Day, Year

Remove Primary Care Fees Only Once the Money Is Found: A Conditional Position on User Fees in a Low-Income Health System

Introduction

Few health financing questions have swung back and forth as often as whether patients in low-income countries should pay at the point of care. Fees were introduced across much of sub-Saharan Africa in the 1980s and 1990s, promoted as a way to raise revenue and discourage unnecessary visits; many of the same governments later abolished them, sometimes overnight before an election. The evidence on both moves is now substantial enough to support a position. This paper argues that fees at primary care facilities in a low-income health system should be removed, conditional on identified public or pooled funds replacing the revenue that facilities lose. Without that condition, removal can harm the households it is meant to protect.

Ground 1: Fees Deter Use of Care

The strongest ground for removal is what fees do to use of services. A Cochrane review of user fee changes in low- and middle-income countries included 16 studies and found that when fees were introduced or increased, use of health services fell significantly in most of them; reducing or removing fees increased use of certain services (Lagarde & Palmer, 2011). The review's authors were cautious, noting methodological weaknesses in most studies and finding no clear evidence on health outcomes or household spending. That caution matters for what this paper can claim. The evidence shows that fees keep people away from clinics. It does not show, on its own, that removing them improves health.

A scoping review of 20 studies of fee abolition in Africa reached a similar conclusion: abolition generally had positive effects on the use of services, but its results depended heavily on how it was implemented, and knowledge of those implementation processes was thin (Ridde & Morestin, 2011). Utilization is therefore the defensible outcome to argue from. If patients who need care stop seeking it because of a charge, the charge is working against the purpose of a primary care system, which is to see problems early and cheaply.

Ground 2: The Revenue Fees Raise Has to Be Priced

The case for removal is incomplete until it accounts for what fees paid for. Many current fees descend from the Bamako Initiative, launched by African health ministers in 1987 to strengthen primary care through community financing and community management. An early evaluation of the Initiative in Burundi, Guinea, Kenya, Nigeria and Uganda found that success in raising revenue was mixed, but that in some countries substantial funds were generated and used to make real improvements in services; it also warned that price structures needed to consider marginalized groups who could not pay even small charges (McPake et al., 1993). In facilities where fee income buys drugs between central deliveries, pays cleaners and tops up staff incentives, that income is not trivial. Removing it without a replacement takes money out of the clinic as patients arrive in larger numbers.

This is why the paper's position is conditional. Replacement financing has to be identified, in amount and source, before fees go: a line in the ministry's budget, a transfer from a pooled insurance fund, or donor support channeled through the national system with a plan for its succession. Commentators who favor removal have made the same argument, describing fee abolition as a step toward universal coverage that must be paired with increased public financing (Yates, 2009).

What Replacement Financing Has to Cover

Pricing the loss means listing what fee income bought in a typical facility before the reform date. Three items usually dominate. The first is medicines purchased locally when central supplies run short, which keep a clinic functioning between deliveries. The second is small payments to staff, often described as incentives, which in some facilities make up a noticeable part of take-home pay. The third is running costs such as cleaning, fuel for a generator and minor repairs. A ministry preparing removal can estimate each from facility accounts for the previous year, then add the cost of the extra visits that removal will bring, since use rises when the charge disappears (Lagarde & Palmer, 2011). The replacement transfer has to arrive at facility level, on a predictable schedule, and in a form managers can spend on the same items. A central budget line that funds salaries but never reaches the clinic's drug account does not replace fee income, however large it looks in the national accounts.

The Strongest Opposing Case

The best argument against removal is not that patients should pay. It is that removal, as many governments have actually done it, damages the system patients rely on. Gilson and McIntyre (2005) accepted the evidence that fees are regressive and contribute to social exclusion, yet warned that removal must be carefully managed because it can harm the wider health system. The mechanism is easy to describe. Abolition announced without new funds raises demand while cutting facility income. Drugs run out, staff who lose incentive payments become less willing to work, and informal charges appear in place of formal ones. A patient who is told care is free and then sent to buy medicines at a private shop may pay more than before and receive less. The Cochrane review itself flagged emerging evidence that fee removal may have unintended effects on preventive services and on service quality (Lagarde & Palmer, 2011).

This objection is serious, and the paper does not answer it by denying it. It answers it by building the objection into the thesis. If removal is harmful mainly when revenue is not replaced, then the right policy is removal with replacement, and the wrong policy is removal as a slogan.

Limits of the Position

The position fails in three circumstances. First, in a fiscal crisis where the ministry cannot fund replacement and donors will not, removal would empty clinics of drugs and should be postponed; a targeted exemption for children under five and pregnant women may be the only defensible step. Second, where fee revenue is a large share of facility income and is spent locally on visible improvements, communities may oppose losing control over it, and removal without a local spending mechanism could weaken community management that the Bamako model built. Third, the evidence base itself is limited: most studies measure utilization over short periods, and few track quality or health outcomes over several years. A government following this paper's advice should therefore monitor drug availability, informal payments and staff attendance in the first year, not only visit counts.

Conclusion

Fees at primary care facilities deter use of care, and the evidence for that is consistent across settings even where individual studies are weak. Fees also fund things clinics need. A ministry that removes them should do so on a date set by the arrival of replacement financing, not by the political calendar. That condition is what separates a reform that widens access from one that only moves the charge from the counter to the pharmacy down the road.

References

Gilson, L., & McIntyre, D. (2005). Removing user fees for primary care in Africa: The need for careful action. BMJ, 331(7519), 762-765. https://doi.org/10.1136/bmj.331.7519.762

Lagarde, M., & Palmer, N. (2011). The impact of user fees on access to health services in low- and middle-income countries. Cochrane Database of Systematic Reviews, (4), Article CD009094. https://doi.org/10.1002/14651858.CD009094

McPake, B., Hanson, K., & Mills, A. (1993). Community financing of health care in Africa: An evaluation of the Bamako initiative. Social Science & Medicine, 36(11), 1383-1395. https://doi.org/10.1016/0277-9536(93)90381-D

Ridde, V., & Morestin, F. (2011). A scoping review of the literature on the abolition of user fees in health care services in Africa. Health Policy and Planning, 26(1), 1-11. https://doi.org/10.1093/heapol/czq021

Yates, R. (2009). Universal health care and the removal of user fees. The Lancet, 373(9680), 2078-2081. https://doi.org/10.1016/S0140-6736(09)60258-0