A process evaluation of user fees abolition for pregnant women and children under five years in two districts in Niger (West Africa)

Abstract

BackgroundAfrican policy-makers are increasingly considering abolishing user fees as a solution to improve access to health care systems. There is little evidence on this subject in West Africa, and particularly in countries that have organized their healthcare system on the basis of the Bamako Initiative. This article presents a process evaluation of an NGO intervention to abolish user fees in Niger for children under five years and pregnant women.MethodsThe intervention was launched in 2006 in two health districts and 43 health centres. The intervention consisted of abolishing user fees and improving the quality of services (drugs, ambulance, etc.). We carried out a process evaluation in April 2007 using qualitative and quantitative data. Three data collection methods were used: i) individual in-depth interviews (n = 85) and focus groups (n = 8); ii) participant observation in 12 health centres; and iii) self-administered structured questionnaires (n = 51 health staff).ResultsThe population favoured abolition; health officials and local decision-makers were in favour, but they worried about its sustainability. Among health workers, opposition to providing free services was more widespread. The strengths of the process were: a top-down phase of information and raising community awareness; appropriate incentive measures; a good drug supply system; and the organization of a medical evacuation system. The major weaknesses of the process were: the perverse effects of incentive bonuses; the lack of community-based management committees' involvement in the management; the creation of a system running in parallel with the BI system; the lack of action to support the service offer; and the poor coordination of the availability of free services at different levels of the health pyramid. Some unintended outcomes are also documented.ConclusionThe linkages between systems in which some patients pay (Bamako Initiative) and some do not should be carefully considered and organized in accordance with the local reality. For the poorest patients to really benefit, it is essential that, at the same time, the quality of services be improved and mechanisms be put in place to prevent abuses. Much remains to be done to generate knowledge on the processes for abolishing fees in West Africa.

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“…Thus the free MCH services can be said to have produced increased demand for health services as most people didn't have to pay out-of-pocket. These increases in utilization after introduction of free services have also been documented by other authors [12,[30][31][32].…”

User fees abolition policy in Niger: Comparing the under five years exemption implementation in two districts

“…The present study shows that ensuring access to medicines and reinforcing the supply system are crucial to the success of such a policy. Moreover, the lessons drawn from a pilot project by another NGO in two districts [12] before the policy was rolled out nationwide were not sufficiently considered. For this type of exemption policy to be adequately implemented, as promoted by world leaders [37], it is urgent that solutions be applied to prevent reverting to user fees (official or unofficial), since people do not understand why a policy that is so beneficial for them would not be fully implemented.…”

“…medicines) [8][9][10]. Healthcare workers are also demanding more involvement in organizational decisions, and populations want to be better informed [9,11,12].…”

Removing the User Fees for the Under-Fives' Simple Malaria Treatment in Cameroon: Effect on the Health Services Utilization

“…The results obtained in other countries are somehow heterogeneous, as the experience of Burkina Faso where the change in utilization was very diverse depending on the district, or the experience of Niger where there was a smaller increase on the utilization of services for U5 in districts where attendance was already low [20].…”