Health for Some? The Effects of User Fees in the Volta Region of Ghana

Abstract

This paper reports key findings and conclusions from a 1996 study of user fees and exemptions in the Volta Region of Ghana. A variety of data sources and methods were used, including interviews with patients and managers, community-based focus group discussions, analysis of facility records and analyses of previous household survey data. Official fee levels and exemption categories were established in 1985. While this legislation made provision for drug fees to be 'at cost' and thus to be revised in line with inflation, other official fees have not been adjusted since 1985. In the face of declining real levels of budget allocations and decreased supplies of essential consumables from the Central medical stores, facility managers have established their own pricing and fee collection systems. This has been allowed by the Ministry of Health, but the decentralized nature of fee setting and collection practices has made it very difficult for the Ministry to monitor the effects of fees. The study found that facility managers have been very active in setting and collecting fees and using the revenues to purchase essential inputs. The level of revenues being mobilized accounts for between two-thirds and four-fifths of the non-salary operating budget of government health facilities, and virtually all of the resources for non-salary operating expenses in mission hospitals. Official exemptions are largely non-functional. Less than one in 1000 patient contacts were granted exemption in 1995. With estimates that between 15 and 30% of the population lives in poverty, the failure of exemptions to function means that fees are preventing access for the poor, or are imposing significant financial hardships on this part of the population. Health facilities in the Volta Region have achieved a kind of 'sustainable inequity', with fees enabling service provision to continue, while concurrently preventing part of the population from using these services.

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

“…There is extensive literature on the impact of user fees in low-to-middle income countries, 1,[3][4][5][19][20][21][22] and the subject of their removal, particularly in Africa, is now a heavily debated issue. The findings of the various studies reported in this paper show that in contexts where poverty is widespread, user fees represent a major obstacle to the use of essential health services and exacerbate impoverishment.…”

“…They add to the evidence that financial barriers associated with user fees contribute significantly to low utilisation of health services. [20][21][22][23][24][25] Under-use of health services is strongly associated with high mortality rates when one considers that a substantial number of deaths are preventable through access to effective health interventions. [26][27][28][29][30] health centres are among other barriers to healthcare access in resource-poor contexts, 26,31,32 some of which were reported in the current surveys.…”

Sustaining the National Health Insurance Scheme in Ghana: Perceptions and Experiences of Health Care Providers and Subscribers

“…This, according to Nyonator and Kutzin, (1999) was essentially a revolving drug fund that was introduced nationwide in 1992. The fee per drug item charged to users was related to the procurement cost of the item, marked-up with fixed percentages by central and regional medical stores.…”

The Experience of Ghana in Implementing a User Fee Exemption Policy to Provide Free Delivery Care

“…7 A study costing maternal health care in one district in 1999 found cost recovery rates of between 152% for deliveries and 211% for caesareans in mission hospitals, but did not shed light on affordability relative to women's income. 10 Problems such as under-funding of exemptions from user fees in general have also been found, [11][12][13] which have meant that exemptions are available in theory but not always in practice if the provider is not reimbursed for lost income.…”