The impact of user fees on health services utilization and infectious disease diagnoses in Neno District, Malawi: a longitudinal, quasi-experimental study

Abstract

BackgroundUser fees have generally fallen out of favor across Africa, and they have been associated with reductions in access to healthcare. We examined the effects of the introduction and removal of user fees on outpatient attendances and new diagnoses of HIV, malaria, and tuberculosis in Neno District, Malawi where user fees were re-instated at three of 13 health centres in 2013 and subsequently removed at one of these in 2015.MethodsWe conducted two analyses. Firstly, an unadjusted comparison of outpatient visits and new diagnoses over three periods between July 2012 and October 2015: during the period with no user fees, at the re-introduction of user fees at four centres, and after the removal of user fees at one centre. Secondly, we estimated a linear model of the effect of user fees on the outcome of interest that controlled for unobserved health centre effects, monthly effects, and a linear time trend.ResultsThe introduction of user fees was associated with a change in total attendances of −68 % [95 % CI: −89 %, −12 %], similar reductions were observed for new malaria and HIV diagnoses. The removal of user fees was associated with an increase in total attendances of 352 % [213 %, 554 %] with similar increases for malaria diagnoses. The results were not sensitive to control group or model specification.ConclusionsUser fees for outpatient healthcare services present a barrier to patients accessing healthcare and reduce detection of serious infectious diseases.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1856-x) contains supplementary material, which is available to authorized users.

Erratum to: The impact of user fees on health services utilization and infectious disease diagnoses in Neno District, Malawi: a longitudinal, quasi-experimental study

“…Upon publication of this article [1], it was brought to our attention that Fig. 1 was incorrectly presented.…”

Effectiveness of antimalarial interventions in Nigeria: Evidence from facility‐level longitudinal data

“…Examples include stock outages of antimalarial commodities, prohibitively costly distance to the nearest provider, the relative shortage of health personnel in malaria control, and social insensitivities in the delivery of antimalarial services . One of the most important barriers remains financial; poorer households are unable to obtain antimalarial services, despite their availability, physical accessibility, and social acceptability.…”

“…To improve access to antimalarial services, many governments have lifted financial barriers and removed user fees. While most studies find a statistically significant association between user‐fee removal and increased utilization of antimalarial services, effectiveness of the policy is still regarded as inconclusive …”

“…Given that the overwhelming methodology of choice is difference‐in‐differences (DD) with routine facility data, shortcomings of the recent literature may be identified. They call into question the credibility of previously estimated results.…”

NGOs, partnerships, and public-private discontent in Nepal’s health care sector

“…Medical bills remain the number one reason people file for bankruptcy in the United States, and 72 percent of those who file have health insurance (Himmelstein et al 2005). In addition to a mound of evidence that suggests that user fees, no matter how small, tend to prevent the poor from accessing care (see for example Farmer et al 2013, 89-90;Pearson 2004;Robert and Ridde 2013;Watson et al 2016), this market logic is exactly the kind of thinking that contributed to the 'under-resourcing' of public-sector health care systems in low-and middle-income countries in the first place. It is easy to forget that the protracted work of strengthening healthcare systems at the center of many PPPs involves coming to terms with, and is often directly linked to, the legacy of neocolonial aid policies like structural adjustment programs.…”