The coping strategies of front-line health workers in the context of user fee exemptions in Niger

Abstract

When user fee exemptions were introduced for children under five years of age in Niger, front-line staff in the health system were not consulted in advance, and various obstacles seriously hindered the policy's implementation. Health workers developed two types of coping strategies. The first dealt with shortcomings of the policy implementation process related to management tools, drug stocks, co-existence of the fee exemption and cost recovery systems, and, above all, supply management for medicines (ordering from private companies, issuing makeshift prescriptions). The second involved clientelism, circumvention of regulations, and misappropriation of resources. Adverse effects have arisen due to both the failings of the health system and the practices of health workers. These include a focus on the commercial management of patients, the most 'costly' of whom sometimes find themselves being refused treatment, patients roaming in search of medicines and treatment, and a decline in quality of care.

Public Servants as Development Brokers: The Shaping of INGOs’ Reducing Teenage Pregnancy Projects in Malawi’s Primary Education Sector

“…This generates a cascade of dynamic responsesbehaviours and relationships arising from within and outside the health systemin relation to policies, 7 which ultimately result in the exclusion of the most vulnerable rural women from maternity care services, against the aim of global and national safe motherhood policies. This ethnographic study supports a growing body of evidence regarding the inequitable effects of user-fees, 8,9,10 problems in relation to "traveling models" (uniform interventions which "travel" from global to local levels) such as skilled birth attendance and user-fee exemption policies, 11,12,13 and the role of multiple actors in the generation and mitigation of problematic policies and their effects. In this way, we illuminate processes leading to inequity, a central challenge to achieving the Global Strategy for Women's, Children's and Adolescents' Health and the Sustainable Development Goals (SDGs).…”

“…11,35,36 Our analysis shows how dynamic responses and accountability relationships 24 can help explain problems with the implementation of policy 36,37 and their inequitable effects when confronted with broader malfunctions of health systems. 12,13,35 This article contributes to understanding processes leading to inequity, which is a central challenge to achieving the Global Strategy for Women's, Children's and Adolescents' health and the SDGs. 14 Global attention to maternal health has contributed to holding governments responsible for maternal mortality and improving health systems' capacity to provide services.…”

When things fall apart: local responses to the reintroduction of user-fees for maternal health services in rural Malawi

“…This generates a cascade of dynamic responsesbehaviours and relationships arising from within and outside the health systemin relation to policies, 7 which ultimately result in the exclusion of the most vulnerable rural women from maternity care services, against the aim of global and national safe motherhood policies. This ethnographic study supports a growing body of evidence regarding the inequitable effects of user-fees, 8,9,10 problems in relation to "traveling models" (uniform interventions which "travel" from global to local levels) such as skilled birth attendance and user-fee exemption policies, 11,12,13 and the role of multiple actors in the generation and mitigation of problematic policies and their effects. In this way, we illuminate processes leading to inequity, a central challenge to achieving the Global Strategy for Women's, Children's and Adolescents' Health and the Sustainable Development Goals (SDGs).…”

“…11,35,36 Our analysis shows how dynamic responses and accountability relationships 24 can help explain problems with the implementation of policy 36,37 and their inequitable effects when confronted with broader malfunctions of health systems. 12,13,35 This article contributes to understanding processes leading to inequity, which is a central challenge to achieving the Global Strategy for Women's, Children's and Adolescents' health and the SDGs. 14 Global attention to maternal health has contributed to holding governments responsible for maternal mortality and improving health systems' capacity to provide services.…”

Effect of a free healthcare policy on health services utilisation for non‐malarial febrile illness by children under five years in Burkina Faso: an interrupted time series analysis

“…It has a positive and sustained effect on the use of child services [11] and contributes to the reduction of infant mortality [12,13]. However, if not implemented as planned or expected, free healthcare policies may also result on unexpected effects such as declining quality of care [14,15], the development of strategies by providers to preserve their personal benefits and informal practices [10], reducing income for healthcare centres and limiting drug's availability [2]. Although it has been proven that in a context of free health care, health workers might find a way to use the system to their own advantage [16], the quality (technical and perceived) of care and the quality of drug prescription do not seem altered in Burkina Faso [17,18].…”