An analysis of the user fee policy for health care in Eritrea

Asbu, Eyob Zere

An analysis of the user fee policy for health care in Eritrea

Thesis / Dissertation

1998

Publisher

University of Cape Town

Department

Department of Sociology

Faculty

Faculty of Humanities

Abstract

The recent upsurge in the interest about financing government health services through user charges has necessitated the conducting of country-specific policy studies in order to monitor the implementation of user fees. This helps to achieve the espoused benefits of the policy and minimize any potential untoward effects. This study was conducted with the objectives of assessing the Eritrean user fee policy that was decreed in February 1996, at all stages from the design to its implementation and the interim effects on revenue generation, efficiency, equity, quality and utilization of services. Primary and secondary data were collected from patients and providers using questionnaire and interview schedules - structured and unstructured. Both open-ended and closed-ended questions were included and covered such issues as socio-economic and demographic characteristics of the respondent, illness and utilization behaviour, and fees and exemptions. The instruments were pre-tested in a small sample of the target population and administered by trained interviewers who had previous experience in health related research. The primary data collection was limited to the capital city for two reasons: firstly, its easy access given the time constraints and, secondly, as a lion's share of the fee revenue is collected in the capital city, it was felt that a close scrutiny at that level could give a preliminary picture of the system as a whole. Respondents were selected randomly and included 100 outpatients, and 50 each of inpatients and health workers (including support staff). Qualitative and quantitative data analysis was done. Descriptive statistics and multivariate regression techniques were employed using the Epi-info and micro-TSP software packages. It was found that the policy, which was an update of a pre-existing one was launched against the background of a favourable macro-economic, political and health sector climate. Fees reduced utilization at the tertiary hospital but did not bring about the required level of efficiency as they did not signal to patients to use the appropriate cost-effective levels of care and the referral system Fee waivers are found to be infrequent, and the process of proving one's indigence at the local administrations is lengthy, thus adversely affecting equity. The cost-recovery ratio for the system as a whole for 1996 was the highest in Sub-Saharan Africa. However, at the lowest health care units, the health stations, the scheme does not seem viable. In some of them, fees could not even cover the salary of the cash collector. Utilization at the primary care units showed a relative increase after implementation of the fee policy, indicating a possible shift of demand from the hospital which is relatively expensive. Though this is in the desired direction, it has a long way to go as many patients are bypassing the nearby primary care facilities . At the sampled health center, patients' willingness and ability to pay was found to be higher than the current fee level However, for the hospital's services, the willingness to pay for the current quality of services was lower than what is currently charged. The study recommends that, for patients bypassing the appropriate primary level facilities, fee levels at the tertiary referral hospital need to be increased so as to promote efficiency. Fee increases at the health centers in the capital city needs to be considered as well. As equity may not be ensured with the current system of entitlement to fee waivers, it is advisable to do a prospective means test. Proxy indicators of indigence should be developed given the income data constraints that make the income-related assessment more difficult. Furthermore, geographical price discrimination is worth considering as the ability to pay of different communities is likely to vary. The MOH should institute negotiations with the Ministry of Finance to retain the fee revenue collected within the health sector, so as to be able to achieve the espoused benefits of user fee policy. Finally the study recommends that such a study be conducted at a large scale and alternative or complementary options of health financing such as health insurance be examined for their feasibility.

Keywords

Health Economics

Reference:

Collections

Masters

Full item page