Hidden costs: The direct and indirect impact of user fees on access to malaria treatment and primary care in Mali
AbstractAbout 20 years after initial calls for the introduction of user fees in health systems in sub-Saharan Africa, a growing coalition is advocating for their removal. Several African countries have abolished user fees for health care for some or all of their citizens. However, fee-for-service health care delivery remains a primary health care funding model in many countries in sub-Saharan Africa. Although the impact of user fees on utilization of health services and household finances has been studied extensively, further research is needed to characterize the multi-faceted health and social problems associated with charging user fees. This ethnographic study aims to identify consequences of user fees on gender inequality, food insecurity, and household decision-making for a group of women living in poverty. Ethnographic life history interviews were conducted with 24 women in Yirimadjo, Mali in 2007. Purposive sampling selected participants across a broad socio-economic spectrum. Semi-structured interviews addressed participants' past medical history, socio-economic status, social and family history, and access to health care. Interview transcripts were coded using the guiding analytical framework of structural violence. Interviews revealed that user fees for health care not only decreased utilization of health services, but also resulted in delayed presentation for care, incomplete or inadequate care, compromised food security and household financial security, and reduced agency for women in health care decision making. The effects of user fees were amplified by conditions of poverty, as well as gender and health inequality; user fees in turn reinforced the inequalities created by those very conditions. The qualitative data reveal multi-faceted health and socioeconomic effects of user fees, and illustrate that user fees for health care may impact quality of care, health outcomes, food insecurity, and gender inequality, in addition to impacting health care utilization and household finances. As many countries consider user fee abolition policies, these findings indicate the need to create a broader evaluation framework—one that can measure the health and socioeconomic impacts of user fee polices and of their removal.
Download InfoIf you experience problems downloading a file, check if you have the proper application to view it first. In case of further problems read the IDEAS help page. Note that these files are not on the IDEAS site. Please be patient as the files may be large.
As the access to this document is restricted, you may want to look for a different version under "Related research" (further below) or search for a different version of it.
Bibliographic InfoArticle provided by Elsevier in its journal Social Science & Medicine.
Volume (Year): 75 (2012)
Issue (Month): 10 ()
Contact details of provider:
Web page: http://www.elsevier.com/wps/find/journaldescription.cws_home/315/description#description
Please report citation or reference errors to , or , if you are the registered author of the cited work, log in to your RePEc Author Service profile, click on "citations" and make appropriate adjustments.:
- Chris D. James & Kara Hanson & Barbara McPake & Dina Balabanova & Davidson Gwatkin & Ian Hopwood & Christina Kirunga & Rudolph Knippenberg & Bruno Meessen & Saul S. Morris & Alexander Preker & Yves So, 2006. "To Retain or Remove User Fees?: Reflections on the Current Debate in Low- and Middle-Income Countries," Applied Health Economics and Health Policy, Springer Healthcare | Adis, vol. 5(3), pages 137-153.
- Michael Kremer & Edward Miguel, 2004.
"The Illusion of Sustainability,"
35, Center for Global Development.
- Kremer, Michael Robert & Miguel, Edward A., 2004. "The Illusion of Sustainability," Center for International and Development Economics Research, Working Paper Series qt94p8w1d7, Center for International and Development Economics Research, Institute for Business and Economic Research, UC Berkeley.
- Michael Kremer & Edward Miguel, 2004. "The Illusion of Sustainability," NBER Working Papers 10324, National Bureau of Economic Research, Inc.
- Thaddeus, Sereen & Maine, Deborah, 1994. "Too far to walk: Maternal mortality in context," Social Science & Medicine, Elsevier, vol. 38(8), pages 1091-1110, April.
- Goel, P. & Ross-Degnan, D. & Berman, P. & Soumerai, S., 1996. "Retail pharmacies in developing countries: A behavior and intervention framework," Social Science & Medicine, Elsevier, vol. 42(8), pages 1155-1161, April.
- Yoder, Richard A., 1989. "Are people willing and able to pay for health services?," Social Science & Medicine, Elsevier, vol. 29(1), pages 35-42, January.
- Ardeshir Sepehri & Robert Chernomas, 2001. "Are user charges efficiency- and equity-enhancing? A critical review of economic literature with particular reference to experience from developing countries," Journal of International Development, John Wiley & Sons, Ltd., vol. 13(2), pages 183-209.
- Gundersen, Craig & Kreider, Brent, 2009.
"Bounding the effects of food insecurity on children's health outcomes,"
Journal of Health Economics,
Elsevier, vol. 28(5), pages 971-983, September.
- Gundersen, Craig & Kreider, Brent, 2008. "Bounding the Effects of Food Insecurity on Children's Health Outcomes," Staff General Research Papers 13008, Iowa State University, Department of Economics.
- Musgrove, Philip, 1986. "What should consumers in poor countries pay for publicly-provided health services?," Social Science & Medicine, Elsevier, vol. 22(3), pages 329-333, January.
- Paul J. Gertler & Luis Locay & Warren C. Sanderson, 1987.
"Are User Fees Regressive? The Welfare Implications of Health Care Financing Proposals in Peru,"
NBER Working Papers
2299, National Bureau of Economic Research, Inc.
- Gertler, Paul & Locay, Luis & Sanderson, Warren, 1987. "Are user fees regressive? : The welfare implications of health care financing proposals in Peru," Journal of Econometrics, Elsevier, vol. 36(1-2), pages 67-88.
- AfDB AfDB, . "The AfDB Statistics Pocketbook 2011," AfDB Statistics Pocketbook, African Development Bank, number 301.
- Haddad, Slim & Fournier, Pierre, 1995. "Quality, cost and utilization of health services in developing countries. A longitudinal study in Zaïre," Social Science & Medicine, Elsevier, vol. 40(6), pages 743-753, March.
- Xu, Ke & Evans, David B. & Kadama, Patrick & Nabyonga, Juliet & Ogwal, Peter Ogwang & Nabukhonzo, Pamela & Aguilar, Ana Mylena, 2006. "Understanding the impact of eliminating user fees: Utilization and catastrophic health expenditures in Uganda," Social Science & Medicine, Elsevier, vol. 62(4), pages 866-876, February.
- Stanton, Bonita & Clemens, John, 1989. "User fees for health care in developing countries: A case study of Bangladesh," Social Science & Medicine, Elsevier, vol. 29(10), pages 1199-1205, January.
- Masiye, Felix & Chitah, Bona M. & McIntyre, Diane, 2010. "From targeted exemptions to user fee abolition in health care: Experience from rural Zambia," Social Science & Medicine, Elsevier, vol. 71(4), pages 743-750, August.
- Deininger, Klaus & Mpuga, Paul, 2004. "Economic and Welfare Effects of the Abolition of Health User Fees : Evidence from Uganda," Policy Research Working Paper Series 3276, The World Bank.
- McIntyre, Diane & Thiede, Michael & Dahlgren, Göran & Whitehead, Margaret, 2006. "What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts?," Social Science & Medicine, Elsevier, vol. 62(4), pages 858-865, February.
For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: (Zhang, Lei).
If you have authored this item and are not yet registered with RePEc, we encourage you to do it here. This allows to link your profile to this item. It also allows you to accept potential citations to this item that we are uncertain about.
If references are entirely missing, you can add them using this form.
If the full references list an item that is present in RePEc, but the system did not link to it, you can help with this form.
If you know of missing items citing this one, you can help us creating those links by adding the relevant references in the same way as above, for each refering item. If you are a registered author of this item, you may also want to check the "citations" tab in your profile, as there may be some citations waiting for confirmation.
Please note that corrections may take a couple of weeks to filter through the various RePEc services.