[afro-nets] Removing user fees for primary care (2)

[Emmanuel Otolorin <eotolorin@jhpiego.net>]

Removing user fees for primary care (2)
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Patrick,

Africa is never short of excellent policy documents and guide-
lines which ordinarily should translate into quality health care
for all. After reading your article, my first reaction was to
agree that the removal of user fees should "under normal circum-
stances" lead to increased utilization of health services and an
improvement in the health of the people. But then numerous
flashes from my temporal hard disk cautioned me. Not withstand-
ing your well-thought out recommendations for managing the re-
moval of user fees, experience has shown that policies like this
hardly ever translate into reality.

For example, when user fees were scrapped in Uganda the expecta-
tion was that government will provide all the necessary funds to
bridge the gaps created by the removal of the user fees. Whether
that happened or not is not for me to judge, but I do remember
visiting facilities that lacked some of the most basic supplies
required for primary health care, months after the removal of
user fees. These were supplies which they did not lack during
the user fee era. Of course, the initial community response was
increased "utilization" of services, or rather increased "atten-
dance" at facilities. Regrettably many of the patients visited
merely to collect a shopping list of supplies and drugs.

Some years ago in Nigeria, some regional governments declared
"free education" and "free health" in their regions. These were
very attractive political slogans that caught the attention of
voters and actually got the politicians elected into office.
However, when it was time to implement the promises, they were
found wanting. The end result was "no education and no health".
The schools lacked basic textbooks, classroom furniture and
teachers, while hospitals didn't even have paper on which to
write the patients information and/or nature of complaints. Pa-
tients were often asked to buy exercise books, gloves, lotions,
drugs, sutures etc, even in the middle of the night when all
shops were closed. Of course, the patients soon discovered the
truth and went back to their private practitioners (both ortho-
dox and traditional). The sad part of this was that sometimes
they even paid more to the traditional herbalist than the user
fees they would have paid in the health facility.

On the positive side, I am also aware that in many countries of
the Middle-East (e.g. Saudi Arabia, Kuwait etc.) where quality
health services are provided free of charge, the health statis-
tics have been remarkably good and are approaching those of the
developed world. This shows that when national assets are used
for the development of the people, the impact can be very im-
pressive. Unlike the oil-rich Middle-East countries, however,
most countries of sub-Saharan Africa cannot afford the cost of a
free national health care service. For some countries, even if
they use 100% of their national budget on health alone, it still
would not be enough. I do acknowledge, however, that they can
all, without exception, do much better than they are currently
doing.

In conclusion, it is always very difficult to choose between "no
health service" and "user fee-paying service". As a health care
provider, I would rather work in a facility where clients pay a
small fee that allows the management to ensure the regular sup-
ply of the most basic things that I need, than be in a facility
where I spend most of my time writing shopping lists for clients
and unnecessarily delaying their treatment. In any case, facili-
ties that implement a user-fee policy must be very liberal in
their exemption policies in order to accommodate the very poor
clients in the community! This is the challenge that facility
managers face.

Emmanuel Otolorin
mailto:eotolorin@jhpiego.net