Analysis of the Public Health User Fee Reforms in Malawi

3021 words (12 pages) Essay

20th Jul 2017 Health Reference this

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RESEARCH PROPOSAL

Research title: The political economy analysis of the implementation of public health user fee reforms in Malawi.

  1. BACKGROUND AND BRIEF LITERATURE REVIEW

The economic crises of the 1970s and 80s led many countries to undergo structural reforms that called for reduced public expenditure for basic services. The reforms resulted in the introduction of cost sharing on the part of beneficiaries (Lucas 1988). In several countries, user fees were imposed as a means to address recurrent costs problems and an extra source of revenue for previously “undervalued” services of professional providers. Countries responded differently to the introduction of user charges depending on domestic political risk and institutional capacity to efficiently administer the fees. With the reforms, public financing of health declined in many countries, and in some cases, private service providers seized the opportunity to fill the gap (Romer, 1986). Although the involvement of private service providers helped to meet demand for those able to pay, it limited access of the poor to the same services due to the prohibitive costs.

Over the past ten years, research on economic growth has demonstrated that human capital is a powerful force in the development process (Becker 1990). In consequence, a sustained increase in this form of capital is crucial for poverty reduction in low-income countries and for an ever rising standard of living. Health is one of the commonly used proxies for human capital – an unobservable magnitude or force that is part and parcel of human beings (Schultz 1960).

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Developing countries are struggling to improve the lives of people living in both rural and urban areas. The big challenge in these countries is lack of resources and problems in allocating the scarce resources. Various governments have prioritized different sectors depending on the needs and demands of the people. Some have prioritized primary education and agriculture while others have prioritized mining and health sector. Developing countries have come up with different interventions purposed to cushion people and be able to manage the risk. Some interventions have taken the form of subsidy while others have taken the form of user fee exemption to mention but two (Schultz 1961).

These interventions sometimes are driven by politics, that is why for one to effectively intervene needs to understand the interplay of politics and economics in the developing countries. Depending on policy makers, some would prefer to implement subsidy programmes while others would have user fees exemption or both. User fees are charges one pays at the point of use. The stated interventions are good for the people but to the larger extent over burden the already struggling economy of the developing countries, (Litvack et al 1993). Consequently, government sectors suffer due to being underfunded which has resulted to poor service delivery defeating the whole purpose of subsidy or user fee exemption. Some countries, thus, they have resorted to meet the deficit through the introduction of user fees. For example, in respective of health for all, Malawi government offers free public health services to everyone in the country (ibid).

Through observation, the public health services in Malawi particularly those in bordering districts such as Mchinji, Nsanje, Mwanza and Mulanje face very stiff competition on health resources because the hospitals in these districts serve even those from the neighboring countries such as Zambia and Mozambique.

Currently with the growing population, government is failing to meet the demand of the free public health services which is manifested through the lack of medical resources in the hospitals. Lack of resources might be because the government has a limited tax base to finance the public health services. For instance, in Daily Times of 18th August, 2014 carried a story that Kamuzu central hospital had suspended all the booked surgeries because the hospital had no medical resources required to carry out operations in the theaters. Burns unit department also suffered the same. In such circumstances the introduction of user fee in public hospitals becomes not an option but a necessity. The user fees may therefore, help in three aspects within health service sector: improving efficiency by moderating demand, containing cost, and mobilize more funds for health care than existing sources provided

  1. PROBLEM STATEMENT

The aim of free public health services in Malawi was to bring equality and equity in accessing health services. It has been argued that with user fees in accessing public health services, the poor people could be disadvantaged. Axiomatically, healthy people make healthy nation and participate actively in the development activities. Defeating the aim of free public health services, it is the same poor people who are now struggling while the better off and even politicians use the private hospitals. Every person has got the right to good quality health, but the poor people in Malawi are now voiceless and spend painfully on the services that were meant to be free. The situation begs a question that are the public services in Malawi really free at all when a person is told to buy aspirin tablets in private hospitals or pharmacies while the public hospitals have given the medicine to undeserving individuals such as those coming from other neighboring countries e.g. Mozambique just because public hospitals in Malawi are free. Poor people are also voiceless and lack responsibility on the hospital resources for it is given to them for free. Hospital workers have been frustrated because their working environment is not conducive since they are forced to work even when they do not have resources and are sometimes frustrated due late or nor payment at all for the extra hours rendered.

Provision of quality health services is one of the social indicators of development. However, looking at the persistent resource shortages in the public health sector, Malawi as a country is far behind the expectation. Optionally, national policy makers in some countries such as Kenya and Mozambique thought to enlarge government revenue base through the introduction and implementation of user fee with an aim of improving services, for example, by improving drug availability and the general quality of health care and extending public health coverage. Therefore, the current study aims at undertaking the political economy analysis of the implementation of public health user fee reforms in Malawi. The study will be guided by the following sampled questions:

  1. What are the challenges towards the implementation of public health user fees in Malawi?
  2. What is the reaction of policy makers towards public health user fee implementation?
  3. Is user fee good option to finance public hospitals
  4. Can Malawi manage to embrace user fee policy (in terms of attitudes, willingness and capacity)
  5. How much is raised from the paying ward in the central hospitals, are the services different from the non-paying ward? If they are different, how do they differ? And how is money used. Has it brought any change?
  6. What are the problems that public hospitals meet?
  1. OBJECTIVES

Main objective: to undertake the political economy analysis of the implementation of public health user fee reforms in Malawi.

  1. SPECIFIC OBJECTIVES
    1. Exploring the historical discourse of public health user fee in Malawi.
    2. Determining the reasons of government failure to introduce and implement user fee in public hospitals.
    3. Analysing how people have been deprived of good health services through free public health services in Malawi.
    4. Comparing the challenges in managing the resources faced in the CHAM hospitals and public hospitals.
    5. Analysing stakeholders’ attitude, willingness and ability to embrace public health user fee implementation policy.
  1. HYPOTHESIS
    1. Poor quality of public health services can motivate public willingness to pay towards some improvement of the services
    2. Inadequate funding leads to poor public health services in Malawi
    3. Malawians are deprived of quality public health services through free public health services.
    4. User fee reform in public health services can lead to efficiency and equity in public health resources in public hospitals.
    5. Politicians wish to introduce public health user fee reform but are deterred by the fear of losing popularity
  2. METHODOLOGY
    1. STUDY DESIGN AND METHODS

The study will mainly use qualitative descriptive and analytical cross sectional approach. Objective 1 and 2 on public health user fee trend and government failure to introduce and implement the same respectively will use qualitative descriptive approach. Whilst objectives 3-5 on analysis of people’s deprivation of good health, comparison of challenges in managing resources and analysis of stakeholder’s attitudes respectively will employ qualitative analytical approach.

  1. STUDY SETTTING

The study will take place in Malawi, population n of people; the ministry of health headquarters in Lilongwe, Malawi’s four central hospitals, n number of district hospitals n community hospitals and n health centers. There are also CHAM facilities, private hospitals and NGOs (both local and international) that support health system. The study will focus in all central hospitals because they provide tertiary management care. The ministry of health, because it is the headquarters, some selected CHAM facilities in four regions and few selected NGOs in Malawi.

  1. TARGET POPULATION

Objective 1-2 will target key informants at the headquarters and in the central hospitals and the reviews of available literature in Malawi. Objective 3 will target the discharged patients in the central hospitals and some community around the selected hospitals. Objective 4 will target the health workers in CHAM and central hospitals. Objective 5 will focus on key informants in NGOs which work with health sector.

  1. SAMPLING STRATEGY

Since the study will employ qualitative design, hence, participants will be selected purposively.

  1. DATA COLLECTION PROCESS

Before data collection, consent will be obtained from the ministry of health head-quarters and all in-charges of the facilities where the study is going to take place. The research will be explained to the participants to seek their informed consent.

Data collection tools will be pre-tested, these will include interview guide for 1) discharged patients to find out any deprivation of their care, 2) health care workers to assess the challenges in resources 3) key informants to analyse their attitudes. And checklist to assess challenges faced by health care workers and patients deprivation of care.

  1. ETHICAL CONSIDERATION

In carrying out the proposed research, the concept of research ethics will not be ignored. All people involved in this research will have to give consent. No one is going to participate against his or her will but the research would prefer to have full participation from the participants and not partial. Attention will be deployed to make sure that people’s rights are not violated through this research. Participants will be told the aim of the research and everything crucial so that they should be able to give informed consent. Participants’ identity will not be revealed in the data presentation and analysis. However, upon request, some participants predominantly NGOs will have the copy of the research findings.

  1. DATA MANAGEMENT

Data will be transcribed from Chichewa to English then themes will be developed from which quantitative data will be analysed while quantitative part will be managed by SPSS. Data will be kept confidential unless strict measures are taken to access the same.

  1. PRESENTATION OF DATA

The data will be presented through quotes and where necessary tables and graphs will be used for the part of quantitative.

  1. THEORETICAL FRAMEWORK

The nature of the research demands SIDA’s Power Analysis framework. The introduction and implementation of public health user fee involves power of various stakeholders who have different powers of influence. The research then aims to analyse and gauge how much power Do these stakeholders have towards the introduction and implementation of user fees in public health services, (Shaw RP et al, 1995).

SIDA’s power analysis focuses on understanding structural factors impeding poverty reduction as well as incentives and disincentives for pro-poor development. Thus, health sector is a hub to development of which the poor have to be targeted. SIDA power analysis tool also serves to stimulate thinking about processes of change in terms of what can be done about formal and informal power relations, power structures and the actors contributing to it. The framework seeks to either deepen knowledge, facilitate dialogue, foster influence or feed into policy developing and programming of which in this case will be the introduction and implementation of user fee in public hospitals (Shaw RP et al, 1995).

In the same vein, political economy analysis also looks at the interaction of formal and informal institutions. The collected data will also be subjected to the critical analysis under the interaction of informal and formal institutions (ibid).

8.0 JUSTIFICATION OF THE RESEARCH

The current research is of paramount importance to the people of Malawi. The study will facilitate the improvement of public health services throughout Malawi. The big problem in the health sector is inadequate resources, consequently, the research is purported to carry out analysis of how public health user fee can be an alternative to financing public hospitals. The improvement in public health services entails healthy people who can actively participate in development activities. The success in the implementation public health user fee will help not to over burden the government because public health hospitals will be able to meet some needs through user fee, hence, the government will be able use the part of budget allocated to the health sector in other sectors of priority.

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The study will provide an insight of development health sector and bring satisfaction to people especially those who use public health services. The study assumes that if the public health user fee reform is implemented, people will access the services of higher quality compared to the current situation in which patients are told to buy the prescribed medication in the private pharmacy because hospitals have no medicine. In this then, the implementation of user fee reduces the cost of accessing public health services in Malawi. No country can develop if the health services are poor. The vitality of the current study cannot be over emphasized, if it will be well done, Malawi as a country will register good health and social development.

REFERENCES

Becker, Gary (1991). A Treatise on the Family. Cambridge, Massachusetts, Harvard University Press.

Lucas, Robert, E. (1988). On the Mechanics of Economic Development. Journal of Monetary Economics 22(1): 3-42.

Pritchett, Lant and Lawrence H. Summers (1996). Wealthier is Healthier. The Journal of Human Resources XXX(4): 841-68.

Schultz, Theodore W (1960). Human Capital Formation by Education, Journal of Political Economy 68(6): 571-83.

Schultz, Theodore W (1963). The Economic Value of Education. New York: Columbia University Press.

Schultz, Theodore W (1961). Investing in Human Capital. The American Economic Review 51(1): 1-17.

Romer, Paul (1986). Increasing Returns and Long Run Growth. Journal of Political Economy 94.

Shaw RP, Griffin C. (1995), SIDA power analysis Washington DC: World Bank

Sophie Witter (2010) Mapping user fees for health care in high-mortality countries: evidence from a recent survey ; HLSP institute

Audibert M, Mathonnat J. 2000. Cost recovery in Mauritania: initial lessons. Health Policy Plan:

Chawla M, Ellis RP. 2000. The impact of financing and quality changes on healthcare demand in

Niger. Health Policy Plan: 76-84.

Lucy Gilson (—–)The Lessons of User Fee Experience in Africa Center for Health Policy, Department of Community Health, University of Witwatersrand, South Africa, and Health Economics and Financing Programme, London School of Hygiene and Tropical Medicine, United Kingdom.

Litvack J, Bodart C. ( 1993) User fees plus quality equals improved access to health care: results of a field experiment in Cameroon. Social Science and Medicine.

Mbugua JK, Bloom GH, Segall MM (1995). Impact of user charges on vulnerable groups: the case of Kibwezi in rural Kenya. Social Science and Medicine.

Moses S, Manji F, Bradley JE, Nagelkerke NJ, Malisa MA, Plummer FA (1992). Impact of user fees on attendance at a referral centre for sexually transmitted diseases in Kenya. Lancet

 

RESEARCH PROPOSAL

Research title: The political economy analysis of the implementation of public health user fee reforms in Malawi.

  1. BACKGROUND AND BRIEF LITERATURE REVIEW

The economic crises of the 1970s and 80s led many countries to undergo structural reforms that called for reduced public expenditure for basic services. The reforms resulted in the introduction of cost sharing on the part of beneficiaries (Lucas 1988). In several countries, user fees were imposed as a means to address recurrent costs problems and an extra source of revenue for previously “undervalued” services of professional providers. Countries responded differently to the introduction of user charges depending on domestic political risk and institutional capacity to efficiently administer the fees. With the reforms, public financing of health declined in many countries, and in some cases, private service providers seized the opportunity to fill the gap (Romer, 1986). Although the involvement of private service providers helped to meet demand for those able to pay, it limited access of the poor to the same services due to the prohibitive costs.

Over the past ten years, research on economic growth has demonstrated that human capital is a powerful force in the development process (Becker 1990). In consequence, a sustained increase in this form of capital is crucial for poverty reduction in low-income countries and for an ever rising standard of living. Health is one of the commonly used proxies for human capital – an unobservable magnitude or force that is part and parcel of human beings (Schultz 1960).

Developing countries are struggling to improve the lives of people living in both rural and urban areas. The big challenge in these countries is lack of resources and problems in allocating the scarce resources. Various governments have prioritized different sectors depending on the needs and demands of the people. Some have prioritized primary education and agriculture while others have prioritized mining and health sector. Developing countries have come up with different interventions purposed to cushion people and be able to manage the risk. Some interventions have taken the form of subsidy while others have taken the form of user fee exemption to mention but two (Schultz 1961).

These interventions sometimes are driven by politics, that is why for one to effectively intervene needs to understand the interplay of politics and economics in the developing countries. Depending on policy makers, some would prefer to implement subsidy programmes while others would have user fees exemption or both. User fees are charges one pays at the point of use. The stated interventions are good for the people but to the larger extent over burden the already struggling economy of the developing countries, (Litvack et al 1993). Consequently, government sectors suffer due to being underfunded which has resulted to poor service delivery defeating the whole purpose of subsidy or user fee exemption. Some countries, thus, they have resorted to meet the deficit through the introduction of user fees. For example, in respective of health for all, Malawi government offers free public health services to everyone in the country (ibid).

Through observation, the public health services in Malawi particularly those in bordering districts such as Mchinji, Nsanje, Mwanza and Mulanje face very stiff competition on health resources because the hospitals in these districts serve even those from the neighboring countries such as Zambia and Mozambique.

Currently with the growing population, government is failing to meet the demand of the free public health services which is manifested through the lack of medical resources in the hospitals. Lack of resources might be because the government has a limited tax base to finance the public health services. For instance, in Daily Times of 18th August, 2014 carried a story that Kamuzu central hospital had suspended all the booked surgeries because the hospital had no medical resources required to carry out operations in the theaters. Burns unit department also suffered the same. In such circumstances the introduction of user fee in public hospitals becomes not an option but a necessity. The user fees may therefore, help in three aspects within health service sector: improving efficiency by moderating demand, containing cost, and mobilize more funds for health care than existing sources provided

  1. PROBLEM STATEMENT

The aim of free public health services in Malawi was to bring equality and equity in accessing health services. It has been argued that with user fees in accessing public health services, the poor people could be disadvantaged. Axiomatically, healthy people make healthy nation and participate actively in the development activities. Defeating the aim of free public health services, it is the same poor people who are now struggling while the better off and even politicians use the private hospitals. Every person has got the right to good quality health, but the poor people in Malawi are now voiceless and spend painfully on the services that were meant to be free. The situation begs a question that are the public services in Malawi really free at all when a person is told to buy aspirin tablets in private hospitals or pharmacies while the public hospitals have given the medicine to undeserving individuals such as those coming from other neighboring countries e.g. Mozambique just because public hospitals in Malawi are free. Poor people are also voiceless and lack responsibility on the hospital resources for it is given to them for free. Hospital workers have been frustrated because their working environment is not conducive since they are forced to work even when they do not have resources and are sometimes frustrated due late or nor payment at all for the extra hours rendered.

Provision of quality health services is one of the social indicators of development. However, looking at the persistent resource shortages in the public health sector, Malawi as a country is far behind the expectation. Optionally, national policy makers in some countries such as Kenya and Mozambique thought to enlarge government revenue base through the introduction and implementation of user fee with an aim of improving services, for example, by improving drug availability and the general quality of health care and extending public health coverage. Therefore, the current study aims at undertaking the political economy analysis of the implementation of public health user fee reforms in Malawi. The study will be guided by the following sampled questions:

  1. What are the challenges towards the implementation of public health user fees in Malawi?
  2. What is the reaction of policy makers towards public health user fee implementation?
  3. Is user fee good option to finance public hospitals
  4. Can Malawi manage to embrace user fee policy (in terms of attitudes, willingness and capacity)
  5. How much is raised from the paying ward in the central hospitals, are the services different from the non-paying ward? If they are different, how do they differ? And how is money used. Has it brought any change?
  6. What are the problems that public hospitals meet?
  1. OBJECTIVES

Main objective: to undertake the political economy analysis of the implementation of public health user fee reforms in Malawi.

  1. SPECIFIC OBJECTIVES
    1. Exploring the historical discourse of public health user fee in Malawi.
    2. Determining the reasons of government failure to introduce and implement user fee in public hospitals.
    3. Analysing how people have been deprived of good health services through free public health services in Malawi.
    4. Comparing the challenges in managing the resources faced in the CHAM hospitals and public hospitals.
    5. Analysing stakeholders’ attitude, willingness and ability to embrace public health user fee implementation policy.
  1. HYPOTHESIS
    1. Poor quality of public health services can motivate public willingness to pay towards some improvement of the services
    2. Inadequate funding leads to poor public health services in Malawi
    3. Malawians are deprived of quality public health services through free public health services.
    4. User fee reform in public health services can lead to efficiency and equity in public health resources in public hospitals.
    5. Politicians wish to introduce public health user fee reform but are deterred by the fear of losing popularity
  2. METHODOLOGY
    1. STUDY DESIGN AND METHODS

The study will mainly use qualitative descriptive and analytical cross sectional approach. Objective 1 and 2 on public health user fee trend and government failure to introduce and implement the same respectively will use qualitative descriptive approach. Whilst objectives 3-5 on analysis of people’s deprivation of good health, comparison of challenges in managing resources and analysis of stakeholder’s attitudes respectively will employ qualitative analytical approach.

  1. STUDY SETTTING

The study will take place in Malawi, population n of people; the ministry of health headquarters in Lilongwe, Malawi’s four central hospitals, n number of district hospitals n community hospitals and n health centers. There are also CHAM facilities, private hospitals and NGOs (both local and international) that support health system. The study will focus in all central hospitals because they provide tertiary management care. The ministry of health, because it is the headquarters, some selected CHAM facilities in four regions and few selected NGOs in Malawi.

  1. TARGET POPULATION

Objective 1-2 will target key informants at the headquarters and in the central hospitals and the reviews of available literature in Malawi. Objective 3 will target the discharged patients in the central hospitals and some community around the selected hospitals. Objective 4 will target the health workers in CHAM and central hospitals. Objective 5 will focus on key informants in NGOs which work with health sector.

  1. SAMPLING STRATEGY

Since the study will employ qualitative design, hence, participants will be selected purposively.

  1. DATA COLLECTION PROCESS

Before data collection, consent will be obtained from the ministry of health head-quarters and all in-charges of the facilities where the study is going to take place. The research will be explained to the participants to seek their informed consent.

Data collection tools will be pre-tested, these will include interview guide for 1) discharged patients to find out any deprivation of their care, 2) health care workers to assess the challenges in resources 3) key informants to analyse their attitudes. And checklist to assess challenges faced by health care workers and patients deprivation of care.

  1. ETHICAL CONSIDERATION

In carrying out the proposed research, the concept of research ethics will not be ignored. All people involved in this research will have to give consent. No one is going to participate against his or her will but the research would prefer to have full participation from the participants and not partial. Attention will be deployed to make sure that people’s rights are not violated through this research. Participants will be told the aim of the research and everything crucial so that they should be able to give informed consent. Participants’ identity will not be revealed in the data presentation and analysis. However, upon request, some participants predominantly NGOs will have the copy of the research findings.

  1. DATA MANAGEMENT

Data will be transcribed from Chichewa to English then themes will be developed from which quantitative data will be analysed while quantitative part will be managed by SPSS. Data will be kept confidential unless strict measures are taken to access the same.

  1. PRESENTATION OF DATA

The data will be presented through quotes and where necessary tables and graphs will be used for the part of quantitative.

  1. THEORETICAL FRAMEWORK

The nature of the research demands SIDA’s Power Analysis framework. The introduction and implementation of public health user fee involves power of various stakeholders who have different powers of influence. The research then aims to analyse and gauge how much power Do these stakeholders have towards the introduction and implementation of user fees in public health services, (Shaw RP et al, 1995).

SIDA’s power analysis focuses on understanding structural factors impeding poverty reduction as well as incentives and disincentives for pro-poor development. Thus, health sector is a hub to development of which the poor have to be targeted. SIDA power analysis tool also serves to stimulate thinking about processes of change in terms of what can be done about formal and informal power relations, power structures and the actors contributing to it. The framework seeks to either deepen knowledge, facilitate dialogue, foster influence or feed into policy developing and programming of which in this case will be the introduction and implementation of user fee in public hospitals (Shaw RP et al, 1995).

In the same vein, political economy analysis also looks at the interaction of formal and informal institutions. The collected data will also be subjected to the critical analysis under the interaction of informal and formal institutions (ibid).

8.0 JUSTIFICATION OF THE RESEARCH

The current research is of paramount importance to the people of Malawi. The study will facilitate the improvement of public health services throughout Malawi. The big problem in the health sector is inadequate resources, consequently, the research is purported to carry out analysis of how public health user fee can be an alternative to financing public hospitals. The improvement in public health services entails healthy people who can actively participate in development activities. The success in the implementation public health user fee will help not to over burden the government because public health hospitals will be able to meet some needs through user fee, hence, the government will be able use the part of budget allocated to the health sector in other sectors of priority.

The study will provide an insight of development health sector and bring satisfaction to people especially those who use public health services. The study assumes that if the public health user fee reform is implemented, people will access the services of higher quality compared to the current situation in which patients are told to buy the prescribed medication in the private pharmacy because hospitals have no medicine. In this then, the implementation of user fee reduces the cost of accessing public health services in Malawi. No country can develop if the health services are poor. The vitality of the current study cannot be over emphasized, if it will be well done, Malawi as a country will register good health and social development.

REFERENCES

Becker, Gary (1991). A Treatise on the Family. Cambridge, Massachusetts, Harvard University Press.

Lucas, Robert, E. (1988). On the Mechanics of Economic Development. Journal of Monetary Economics 22(1): 3-42.

Pritchett, Lant and Lawrence H. Summers (1996). Wealthier is Healthier. The Journal of Human Resources XXX(4): 841-68.

Schultz, Theodore W (1960). Human Capital Formation by Education, Journal of Political Economy 68(6): 571-83.

Schultz, Theodore W (1963). The Economic Value of Education. New York: Columbia University Press.

Schultz, Theodore W (1961). Investing in Human Capital. The American Economic Review 51(1): 1-17.

Romer, Paul (1986). Increasing Returns and Long Run Growth. Journal of Political Economy 94.

Shaw RP, Griffin C. (1995), SIDA power analysis Washington DC: World Bank

Sophie Witter (2010) Mapping user fees for health care in high-mortality countries: evidence from a recent survey ; HLSP institute

Audibert M, Mathonnat J. 2000. Cost recovery in Mauritania: initial lessons. Health Policy Plan:

Chawla M, Ellis RP. 2000. The impact of financing and quality changes on healthcare demand in

Niger. Health Policy Plan: 76-84.

Lucy Gilson (—–)The Lessons of User Fee Experience in Africa Center for Health Policy, Department of Community Health, University of Witwatersrand, South Africa, and Health Economics and Financing Programme, London School of Hygiene and Tropical Medicine, United Kingdom.

Litvack J, Bodart C. ( 1993) User fees plus quality equals improved access to health care: results of a field experiment in Cameroon. Social Science and Medicine.

Mbugua JK, Bloom GH, Segall MM (1995). Impact of user charges on vulnerable groups: the case of Kibwezi in rural Kenya. Social Science and Medicine.

Moses S, Manji F, Bradley JE, Nagelkerke NJ, Malisa MA, Plummer FA (1992). Impact of user fees on attendance at a referral centre for sexually transmitted diseases in Kenya. Lancet

 

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