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Understanding the impact of eliminating user fees: Utilization and catastrophic health expenditures in Uganda

Listed author(s):
  • Xu, Ke
  • Evans, David B.
  • Kadama, Patrick
  • Nabyonga, Juliet
  • Ogwal, Peter Ogwang
  • Nabukhonzo, Pamela
  • Aguilar, Ana Mylena
Registered author(s):

    There is currently considerable discussion between governments, international agencies, bilateral donors and advocacy groups on whether user fees levied at government health facilities in poor countries should be abolished. It is claimed that this would lead to greater access for the poor and reduce the risks of catastrophic health expenditures if all other factors remained constant, though other factors rarely remain constant in practice. Accordingly, it is important to understand what has actually happened when user fees have been abolished, and why. All fees at first level government health facilities in Uganda were removed in March 2001. This study explores the impact on health service utilization and catastrophic health expenditures using data from National Household Surveys undertaken in 1997, 2000 and 2003. Utilization increased for the non-poor, but at a lower rate than it had in the period immediately before fees were abolished. Utilization among the poor increased much more rapidly after the abolition of fees than beforehand. Unexpectedly, the incidence of catastrophic health expenditure among the poor did not fall. The most likely explanation is that frequent unavailability of drugs at government facilities after 2001 forced patients to purchase from private pharmacies. Informal payments to health workers may also have increased to offset the lost revenue from fees. Countries thinking of removing user charges should first examine what types of activities and inputs at the facility level are funded from the revenue collected by fees, and then develop mechanisms to ensure that these activities can be sustained subsequently.

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    File URL: http://www.sciencedirect.com/science/article/pii/S0277-9536(05)00366-7
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    Article provided by Elsevier in its journal Social Science & Medicine.

    Volume (Year): 62 (2006)
    Issue (Month): 4 (February)
    Pages: 866-876

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    Handle: RePEc:eee:socmed:v:62:y:2006:i:4:p:866-876
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    1. Thomason, Jane & Mulou, Navy & Bass, Caroline, 1994. "User charges for rural health services in Papua New Guinea," Social Science & Medicine, Elsevier, vol. 39(8), pages 1105-1115, October.
    2. Gilson, Lucy & Mills, Anne, 1995. "Health sector reforms in sub-Saharan Africa: lessons of the last 10 years," Health Policy, Elsevier, vol. 32(1-3), pages 215-243.
    3. McPake, Barbara & Hanson, Kara & Mills, Anne, 1993. "Community financing of health care in Africa: An evaluation of the Bamako initiative," Social Science & Medicine, Elsevier, vol. 36(11), pages 1383-1395, June.
    4. McPake, Barbara & Asiimwe, Delius & Mwesigye, Francis & Ofumbi, Mathias & Ortenblad, Lisbeth & Streefland, Pieter & Turinde, Asaph, 1999. "Informal economic activities of public health workers in Uganda: implications for quality and accessibility of care," Social Science & Medicine, Elsevier, vol. 49(7), pages 849-865, October.
    5. Catharina Hjortsberg, 2003. "Why do the sick not utilise health care? The case of Zambia," Health Economics, John Wiley & Sons, Ltd., vol. 12(9), pages 755-770.
    6. Adam Wagstaff & Eddy van Doorslaer, 2003. "Catastrophe and impoverishment in paying for health care: with applications to Vietnam 1993-1998," Health Economics, John Wiley & Sons, Ltd., vol. 12(11), pages 921-933.
    7. Carle C. Zimmerman, 1932. "Ernst Engel's Law of Expenditures for Food," The Quarterly Journal of Economics, Oxford University Press, vol. 47(1), pages 78-101.
    8. McPake, Barbara, 1993. "User charges for health services in developing countries: A review of the economic literature," Social Science & Medicine, Elsevier, vol. 36(11), pages 1397-1405, June.
    9. Menno Pradhan & Nicholas Prescott, 2002. "Social risk management options for medical care in Indonesia," Health Economics, John Wiley & Sons, Ltd., vol. 11(5), pages 431-446.
    10. Bouis, Howarth E., 1994. "The effect of income on demand for food in poor countries: Are our food consumption databases giving us reliable estimates?," Journal of Development Economics, Elsevier, vol. 44(1), pages 199-226, June.
    11. Litvack, Jennie I. & Bodart, Claude, 1993. "User fees plus quality equals improved access to health care: Results of a field experiment in Cameroon," Social Science & Medicine, Elsevier, vol. 37(3), pages 369-383, August.
    12. Gilson, Lucy, 1995. "Management and health care reform in sub-Saharan Africa," Social Science & Medicine, Elsevier, vol. 40(5), pages 695-710, March.
    13. Deaton, Angus, 1992. "Understanding Consumption," OUP Catalogue, Oxford University Press, number 9780198288244, April.
    14. Akashi, Hidechika & Yamada, Takako & Huot, Eng & Kanal, Koum & Sugimoto, Takao, 2004. "User fees at a public hospital in Cambodia: effects on hospital performance and provider attitudes," Social Science & Medicine, Elsevier, vol. 58(3), pages 553-564, February.
    15. 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.
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