Removing financial barriers to access reproductive, maternal and newborn health services: the challenges and policy implications for human resources for health

Abstract

BackgroundThe last decade has seen widespread retreat from user fees with the intention to reduce financial constraints to users in accessing health care and in particular improving access to reproductive, maternal and newborn health services. This has had important benefits in reducing financial barriers to access in a number of settings. If the policies work as intended, service utilization rates increase. However this increases workloads for health staff and at the same time, the loss of user fee revenues can imply that health workers lose bonuses or allowances, or that it becomes more difficult to ensure uninterrupted supplies of health care inputs.This research aimed to assess how policies reducing demand-side barriers to access to health care have affected service delivery with a particular focus on human resources for health.MethodsWe undertook case studies in five countries (Ghana, Nepal, Sierra Leone, Zambia and Zimbabwe). In each we reviewed financing and HRH policies, considered the impact financing policy change had made on health service utilization rates, analysed the distribution of health staff and their actual and potential workloads, and compared remuneration terms in the public sectors.ResultsWe question a number of common assumptions about the financing and human resource inter-relationships. The impact of fee removal on utilization levels is mostly not sustained or supported by all the evidence. Shortages of human resources for health at the national level are not universal; maldistribution within countries is the greater problem. Low salaries are not universal; most of the countries pay health workers well by national benchmarks.ConclusionsThe interconnectedness between user fee policy and HRH situations proves difficult to assess. Many policies have been changing over the relevant period, some clearly and others possibly in response to problems identified associated with financing policy change. Other relevant variables have also changed.However, as is now well-recognised in the user fee literature, co-ordination of health financing and human resource policies is essential. This appears less well recognised in the human resources literature. This coordination involves considering user charges, resource availability at health facility level, health worker pay, terms and conditions, and recruitment in tandem. All these policies need to be effectively monitored in their processes as well as outcomes, but sufficient data are not collected for this purpose.

Nurses’ perceptions of universal health coverage and its implications for the Kenyan health sector

“…There was evidence that this may be temporary, as some nurses suggested that quality issues in the public sector spurred the volume of patients in private facilities to return to what it was before the policy implementation. This finding is consistent with research in five other African countries that also found that high levels of utilization in public facilities were not sustained following removal of fees (McPake et al 2013). Furthermore, nurses alluded to a sense of injustice, not only at having not been consulted about the policy change, but also from being told that their work load will increase significantly without increasing their pay.…”

Barriers in the access, diagnosis and treatment completion for tuberculosis patients in central and western Nepal: A qualitative study among patients, community members and health care workers

“…Human resources are the critical elements for the functioning of peripheral health structures globally [27,28] and more importantly in resource-constrained settings of Nepal [29][30][31]. As has been established previously, human resources act as the first interface between the patients and the peripheral health centres [27].…”

How effective and fair is user fee removal? Evidence from Zambia using a pooled synthetic control

“…There are reasons to believe that changes in prices happened in conjunction with changes in quality of care and that the perceived quality of care diminished in the public sector. Indeed, in Zambia, the health financing reform took place against the backdrop of a critical shortage of health workers, which affected particularly remote and rural areas (Carasso, Lagarde, Cheelo, Chansa, & Palmer, ; McPake et al, ). As a result, it is possible that populations in rural areas would expect relatively low quality of services in the public sector after fees were removed, mitigating their valuation of these free services.…”