No cash, no care: how user fees endanger health—lessons learnt regarding financial barriers to healthcare services in Burundi, Sierra Leone, Democratic Republic of Congo, Chad, Haiti and Mali

Ponsar, Frederique; Tayler‐Smith, Katie; Philips, Mit; Gerard, Seco; Herp, Michel Van; Reid, Tony; Zachariah, Rony

doi:10.1016/j.inhe.2011.01.002

Cited by 50 publications

(49 citation statements)

References 24 publications

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“…Certainly, the health status of the population with one of the highest maternal mortality rates in the world, as well as emerging evidence of financial barriers in access to healthcare, played an important part in promoting the policy ( [44] & KII). However, even more critical seems to be the role of the President and the lead he took to include the FHCI among the government’s priorities.…”

Section: Findings: the Unfolding ‘Policy Story’mentioning

confidence: 99%

A window of opportunity for reform in post-conflict settings? The case of Human Resources for Health policies in Sierra Leone, 2002–2012

et al. 2014

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BackgroundIt is recognized that decisions taken in the early recovery period may affect the development of health systems. Additionally, some suggest that the immediate post-conflict period may allow for the opening of a political ‘window of opportunity’ for reform. For these reasons, it is useful to reflect on the policy space that exists in this period, by what it is shaped, how decisions are made, and what are their long-term implications. Examining the policy trajectory and its determinants can be helpful to explore the specific features of the post-conflict policy-making environment. With this aim, the study looks at the development of policies on human resources for health (HRH) in Sierra Leone over the decade after the conflict (2002–2012).MethodsMultiple sources were used to collect qualitative data on the period between 2002 and 2012: a stakeholder mapping workshop, a document review and a series of key informant interviews. The analysis draws from political economy and policy analysis tools, focusing on the drivers of reform, the processes, the contextual features, and the actors and agendas.FindingsOur findings identify three stages of policy-making. At first characterized by political uncertainty, incremental policies and stop-gap measures, the context substantially changed in 2009. The launch of the Free Health Care Initiative provided to be an instrumental event and catalyst for health system, and HRH, reform. However, after the launch of the initiative, the pace of HRH decision-making again slowed down.ConclusionsOur study identifies the key drivers of HRH policy trajectory in Sierra Leone: (i) the political situation, at first uncertain and later on more defined; (ii) the availability of funding and the stances of agencies providing such funds; (iii) the sense of need for radical change – which is perhaps the only element related to the post-conflict setting. It also emerges that a ‘windows of opportunity’ for reform did not open in the immediate post-conflict, but rather 8 years later when the Free Health Care Initiative was announced, thus making it difficult to link it directly to the features of the post-conflict policy-making environment.

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Section: Findings: the Unfolding ‘Policy Story’mentioning

confidence: 99%

A window of opportunity for reform in post-conflict settings? The case of Human Resources for Health policies in Sierra Leone, 2002–2012

et al. 2014

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“…Ponsar et al . [5] showed that user fees in several African countries may present significant barriers for accessing health-care and can result in the exclusion of vulnerable individuals. They suggested a mechanism of user fee abolition combined with compensation of health facilities for the lost revenue.…”

Section: Introductionmentioning

confidence: 99%

“…To date, qualitative studies on patients’ perceptions of user fees have been previously conducted in the Democratic Republic of Congo (DRC) [5] but there have been no quantitative studies on user fee subsidisation in this context. This study aimed to address this gap by answering the following research question: what are the effects on health-care utilisation of a policy to subsidise user fees in the DRC?…”

Section: Introductionmentioning

confidence: 99%

Picking up the bill - improving health-care utilisation in the Democratic Republic of Congo through user fee subsidisation: a before and after study

Maini¹,

Bergh

Griensven

et al. 2014

BMC Health Serv Res

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BackgroundUser fees have been shown to constitute a major barrier to the utilisation of health-care, particularly in low-income countries such as the Democratic Republic of Congo (DRC). Importantly, such barriers can lead to the exclusion of vulnerable individuals from health-care. In 2008, a donor-funded primary health-care programme began implementing user fee subsidisation in 20 health zones of the DRC. In this study, we quantified the short and long-term effects of this policy on health-care utilisation.MethodsSixteen health zones were included for analysis. Using routinely collected health-care utilisation data before and after policy implementation, interrupted time series regression was applied to quantify the temporal impact of the user fee policy in the studied health zones. Payment of salary supplements to health-care workers and provision of free drugs - the other components of the programme - were controlled for where possible.ResultsFourteen (88%) health zones showed an immediate positive effect in health-care utilisation rates (overall median increase of 19%, interquartile range 11 to 43) one month after the policy was introduced, and the effect was significant in seven zones (P <0.05). This initial effect was sustained or increased at 24 months in five health zones but was only significant in one health zone at P <0.05. Utilisation reduced over time in the remaining health zones (overall median increase of 4%, interquartile range −10 to 33). The modelled mean health-care utilisation rate initially increased significantly from 43 consultations/1000 population to 51 consultations/1000 population during the first month following implementation (P <0.01). However, the on-going effect was not significant (P =0.69).ConclusionsOur research brings mixed findings on the effectiveness of user fee subsidisation as a strategy to increase the utilisation of services. Future work should focus on feasibility issues associated with the removal or reduction of user fees and how to sustain its effects on utilisation in the longer term.

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“…A study published by the Médecins Sans Frontières concluded that the no cash-no care policy in Sierra Leone and other developing countries was placing a financial barrier to patients in need of care [22]. Many reports have documented the rise in NCDs in poorer countries, coupled with the undue burden these diseases place on an already fragile infrastructure.…”

Section: Discussion and Study Limitationsmentioning

confidence: 99%

A Cross-Sectional Survey to Determine the Prevalence of Cardiovascular Disease Risk Factors in an Understudied Population in Sierra Leone

Strasserking¹,

Bick²,

Russell³

et al. 2016

WJCD

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To document the prevalence of risk factors for cardiovascular disease in an unstudied community, a survey of 130 participants from different areas of Sierra Leone was performed. The focus was on cardiovascular disease because its prevalence had not been studied and World Health Organization (WHO) reports on Non-Communicable Diseases (NCD) prevalence were extrapolations and not from actual data. Resting blood pressure, fasting blood glucose, fasting lipid levels and carotid intima media thickness (CIMT) were measured. Mean blood pressure in men was slightly lower than in women (132/87 mmHg and 139/90 mmHg respectively), mean fasting blood glucose levels were <100 mg/dL in both groups and mean fasting total cholesterol was higher in women than in men (206 mg versus 193.5 mg/dL). Mean fasting low density lipoprotein levels were similar in both groups, 129 mg/dL in men and 133 mg/dL in women. Mean fasting high density cholesterol was 47.2 mg/dL in men and 55.5 mg/dL in women and CIMT values were similar in both groups, with 60% above the 75 th percentile. This study demonstrated a prevalence of cardiovascular risk factors in this population with mean BP placing both men and women in pre-hypertension or stage 1 hypertension ranges and elevated mean low density lipoprotein levels. Fasting total cholesterol, blood glucose and high density lipoprotein were within normal ranges. Mean CIMT values for men and women placed them at risk for subclinical atherosclerosis.

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No cash, no care: how user fees endanger health—lessons learnt regarding financial barriers to healthcare services in Burundi, Sierra Leone, Democratic Republic of Congo, Chad, Haiti and Mali

Cited by 50 publications

References 24 publications

A window of opportunity for reform in post-conflict settings? The case of Human Resources for Health policies in Sierra Leone, 2002–2012

A window of opportunity for reform in post-conflict settings? The case of Human Resources for Health policies in Sierra Leone, 2002–2012

Picking up the bill - improving health-care utilisation in the Democratic Republic of Congo through user fee subsidisation: a before and after study

A Cross-Sectional Survey to Determine the Prevalence of Cardiovascular Disease Risk Factors in an Understudied Population in Sierra Leone

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