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

Human Resources for Health

Yotamu Chirwa³  Tim Martineau⁵  David Newlands²  Suzanne Fustukian¹  Tim Ensor⁴  Sophie Witter¹  Barbara McPake¹ 

[1] Institute for International Health and Development, Queen Margaret University, Edinburgh, UK;Department of Economics, University of Aberdeen, Aberdeen, UK;Biomedical Research and Training Institute, Harare, Zimbabwe;Nuffield Institute for Global Health, University of Leeds, Leeds, UK;Liverpool School of Tropical Medicine, Liverpool, UK

关键词: Pay;    Workload;    Distribution;    Policy co-ordination;    Human resources for health;    User fees;   

Others  :  822340
DOI  :  10.1186/1478-4491-11-46

 received in 2013-01-17, accepted in 2013-08-29,  发布年份 2013

【 摘 要 】

Background

The 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.

Methods

We 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.

Results

We 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.

Conclusions

The 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.

【 授权许可】

   
2013 McPake et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Fig. 6.

【 参考文献 】

• [1]Holmes D: Margaret Chan: committed to increased health coverage. Lancet 2012, 380:879.
• [2]Hulme D: The Millennium Development Goals (MDGs): A short history of the world’s biggest promise, Brooks World Poverty Institute Working Paper 100, University of Manchester. [http://www.bwpi.manchester.ac.uk/resources/Working-Papers/bwpi-wp-10009.pdf webcite]
• [3]Yates R: Universal health care and the removal of user fees. Lancet 2009, 373:2078-2081.
• [4]Kruk ME, Mbaruku G, Rockers PC, Galea S: User fee exemptions are not enough: out-of-pocket payments for 'free’ delivery services in rural Tanzania. Trop Med Int Health 2008, 13:1442-1451.
• [5]Campbell J, Oulton JA, McPake B, Buchan J: Increasing access to 'free’ health services: are health workers not a missing link? Int J Clin Pract 2011, 65:12-15.
• [6]Witter S: Mapping user fees for health care in high-mortality countries: evidence from a recent survey. London: HLSP Institute; 2010.
• [7]UNICEF: Maternal and Child Health: The Social Protection Dividend - West and Central Africa. Regional Thematic Report 4. Dakar: UNICEF Regional Office for West and Central Africa; 2009.
• [8]McPake B: User charges for health services in developing countries: a review of the economic literature. Soc Sci Med 1993, 36:1397-1405.
• [9]Gilson L, McIntyre D: Removing user fees for primary care in Africa: the need for careful action. BMJ 2005, 331:762-765.
• [10]Witter S: An Unnecessary Evil? User fees for healthcare in low-income countries. London: Save the Children Fund; 2005.
• [11]James C, Hanson K, McPake B, Balabanova D, Gwatkin D, Hopwood I, Kirunga C, Knippenberg R, Meessen B, Morris S, Preker A, Soucat A, Souteyrand Y, Tibouti A, Villeneuved P, Xuh K: To retain or remove user fees? Reflections on the current debate in low- and middle-income countries. Appl Health Econ Health Policy 2006, 5:137-153.
• [12]World Health Organization: WHO Meeting on User Fee Impact On Access And Equity And On Lessons Learnt For the Pacific. Geneva: World Health Organization; 2008.
• [13]Meessen B, Hercot D, Noirhomme M, Ridde V, Tibouti A, Bicaba A, Kirunga Tashobya C, Gilson L: Removing User Fees in the Health Sector in Low-Income Countries – A Multi-Country Review. New York: UNICEF; 2009.
• [14]Witter S, Khadka S, Nath H, Tiwari S: The national free delivery policy in Nepal: early evidence of its effects on health facilities. Health Policy Plan 2011, 26(Suppl 2):84-91.
• [15]Ridde V, Haddad S: Abolishing user fees in Africa. PloS Med 2009, 6(1):e1000008.
• [16]Hofmeyr GJ, Haws RA, Bergström S, Lee ACC, Okong P, Darmstadt GL, Mullany LC, ShweOo EK, Lawn JE: Obstetric care in low-resource settings: what, who, and how to overcome challenges to scale up? Int J Gynaecol Obstet 2009, 107:S21-S45.
• [17]Lee ACC, Lawn JE, Cousens S, Kumar V, Osrin D, Bhutrta ZA, Wall SN, Nandakumar AK, Syed U, Darmstadt GL: Linking families and facilities for care at birth: what works to avert intrapartum-related deaths? Int J Gynaecol Obstet 2009, 107(Suppl 1):S65-S88.
• [18]Witter S, Kusi A, Aikins M: Working practices and incomes of health workers: a delivery Evidence from an evaluation of fee exemption scheme in Ghana. Hum Resour Health 2007, 5:2. BioMed Central Full Text
• [19]Penfold S, Harrison E, Bell J, Fitzmaurice A: Evaluation of the delivery-fee-exemption policy in Ghana: population estimates of changes in delivery service utilisation in two regions. Ghana Med J 2007, 41:100-109.
• [20]El-Khoury M, Gandaho T, Arur A, Keita B, Nichols L: Improving Access to Life Saving Maternal Health Services: The Effects of Removing User Fees for Caesareans in Mali. Bethesda, MD: Health Systems 20/20; 2011.
• [21]Witter S, Dieng T, Mbengue D, Moreira I, De Brouwere V: The national free delivery and caesarean policy in Senegal: evaluating process and outcomes. Health Policy Plan 2010, 25:384-392.
• [22]Altaras R: Increasing Financial Access to Primary Health Care for the Rural Poor: A study on changes in health service use and costs following the removal of user fees in the Grande Anse, Haiti. Paris, France: Médecins du Monde France; 2009.
• [23]Witter S, Arhinful DK, Kusi A, Zakariah-Akoto S: The Experience of Ghana in Implementing a User Fee Exemption Policy to Provide Free Delivery Care. Reprod Health Matters 2007, 15:61-71.
• [24]Burnham GM, Pariyo G, Galiwango E, Wabwire-Mange F: Discontinuation of cost sharing in Uganda. Bull World Health Organ 2004, 82:187-195.
• [25]McPake B, Brikci N, Cometto G, Schmidt A, Araujo E: Removing user fees: learning from international experience to support the process. Health Policy Plan 2011, 26(Suppl 2):ii104-ii117.
• [26]Ridde V, Morestin F: A scoping review of the literature on the abolition of user fees in health care services in Africa. Health Policy Plan 2011, 26:1-11.
• [27]Witter S, Adjei S, Armar-Klemesu M, Graham W: Providing free maternal health care: ten lessons from an evaluation of the national delivery exemption policy in Ghana. Global Health Action 2009, 2:1-5.
• [28]Steinhardt LC, Aman I, Pakzad I, Kumar B, Singh LP, Peters DH: Removing user fees for basic health services: a pilot study and national roll-out in Afghanistan. Health Policy Plan 2011, 26(Suppl ii):92-103.
• [29]Cheelo C, Chama C, Pollen G, Carasso B, Palmer N, Jonsson D, Lagarde M, Chansa C: Do User Fee Revenues Matter? Assessing the Influences of the Removal of User Fees on Health Financial Resources in Zambia. Department of Economics, Working Paper No. 2010/1. Lusaka: University of Zambia; 2010.
• [30]Ssengooba F, Rahman SA, Hongoro C, Rutebemberwa E, Mustafa A, Kielmann T, McPake B: Health sector reforms and human resources for health in Uganda and Bangladesh: mechanisms of effect. Hum Resour Health 2007, 5:3. BioMed Central Full Text
• [31]Kipp W, Kamugisha J, Jacobs P, Burnham G, Rubaale T: User fees, health staff incentives, and service utilization in Kabarole District Uganda. Bull World Health Organ 2001, 79:1032-1037.
• [32]Nabyonga-Orem J, Karamagi H, Atuyambe L, Bagenda F, Okuonzi SA, Walker O: Maintaining quality of health services after abolition of user fees: a Uganda case study. BMC Health Serv Res 2008, 8:102. BioMed Central Full Text
• [33]Nimpagaritse M, Bertone MP: The sudden removal of user fees: the perspective of a frontline manager in Burundi. Health Policy Plan 2011, 26(Suppl 2):ii63-ii71.
• [34]Walker L, Gilson L: 'We are bitter but we are satisfied’: nurses as street-level bureaucrats in South Africa. Soc Sci Med 2004, 59:1251-1261.
• [35]Masiye F, Chitah BM, McIntyre D: From targeted exemptions to user fee abolition in health care: experience from rural Zambia. Soc Sci Med 2010, 71:743-750.
• [36]Nabyonga-Orem J, Mugisha F, Kirunga C, Macq J, Criel B: Abolition of user fees: the Uganda paradox. Health Policy Plan 2011, 26(Suppl 2):ii41-ii51.
• [37]Xu K, Evans DB, Kadama P, Nabyonga J, Ogwal PO, Nabukhonzo P, Aguilar AM: Understanding the impact of eliminating user fees: Utilization and catastrophic health expenditures in Uganda. Soc Sci Med 2006, 62:866-876.
• [38]Yates J, Cooper R, Holland J: Social protection and health: experiences in Uganda. Dev Policy Rev 2006, 24:339-356.
• [39]Cheelo C, Chama C, Pollen G, Carasso B, Palmer N, Jonsson D, Lagarde M, Chansa C: Do user fee revenues matter: assessing the influences of the removal of user fees on health financial resources in Zambia. Working Paper No. 2010/1. [http://www.unza.zm/Economics/downloads/Working%20paper%20Series/Do%20User%20Fees%20Matter_User%20Fee%20Removal_WPS%202010-1.pdf webcite] (accessed 15 March 2013)
• [40]Ridde V, Diarra A: A process evaluation of user fees abolition for pregnant women and children under five years in two districts in Niger (West Africa). BMC Health Serv Res 2009, 9:1-16. BioMed Central Full Text
• [41]ten Hoope-Bender P, Liljestrand J, MacDonagh S: Human resources and access to maternal health care. Int J Gynaecol Obstet 2006, 94:226-233.
• [42]Lawn JE, Kinney M, Lee A, Chopra M, Donnay F, Paul VK, Bhutta ZA, Bateman M, Darmstadt GL: Reducing intrapartum-related deaths and disability: can the health system deliver? Int J Gynaecol Obstet 2009, 107:S123-S142.
• [43]Sulzbach S: Evaluating the Impact of National Health Insurance in Ghana (presentation). Health Systems 20/20, Accra 2008,  .
• [44]Witter S, Garshong B: Something old or something new? Social health insurance in Ghana. BMC Int Health Hum Rights 2009, 9:20. BioMed Central Full Text
• [45]Leger F: Financial assessment of the NHIF. Geneva: ILO; 2006.
• [46]World Health Organisation: Measuring service availability and readiness: A health facility assessment methodology for monitoring health system strengthening, Service availability indicators. [http://www.who.int/healthinfo/systems/SARA_ServiceAvailabilityIndicators.pdf webcite] (accessed 15 March 2013)
• [47]Powell-Jackson T, Tiwari S, Neupane B, Singh M: An early evaluation of the Aama free delivery care programme. Kathmandu: SSMP; 2010.
• [48]Ministry of Health and Sanitation: Health Sector Performance Review, Scaling up Maternal and Child Health Services in Sierra Leone. Freetown: Government of Sierra Leone; 2010.
• [49]Liaqat S, Ferry J: Free Health Care Six Months On: What Does it Mean for Child Health in Northern Bombali?. London: Health Poverty Action; 2011.
• [50]Bijlmakers LA, Bassett M, Sanders D: Health and Structural Adjustment in Rural and Urban Zimbabwe. Uppsala: Research Report No. 101; 1996.
• [51]Ministry of Health Zambia, London School of Hygiene and Tropical Medicine, University of Zambia, University of Cape Town: Exploring the Effects of User Fee removal in Zambia: Summary of Findings. London: London School of Hygiene and Tropical Medicine Briefing paper 2; 2010. [http://www.anglicanhealth.org/Resources/PDF/AHN%20resources/Health%20financing%20and%20Insurance/Policy%20brief%202_summary%20findings%20FINAL.pdf webcite] (accessed 15 March 2013)
• [52]Chirwa Y, Witter S, Munjoma M, Mashange W, Ensor T, McPake B, Munyati S: The human resource implications of improving financial risk protection for mothers and newborns in Zimbabwe. BMC Health Serv Res 2013, 13:197. BioMed Central Full Text
• [53]Herbst C, Vledder M, Campbell K, Sjöblom M, Soucat A: The Human Resources for Health Crisis in Zambia, World Bank. [https://openknowledge.worldbank.org/handle/10986/5938 webcite] (accessed 15 March 2013)
• [54]Hongoro C, Kumaranayake L: Do they work? Regulating for-profit providers in Zimbabwe. Health Policy Plan 2000, 15:368-378.
• [55]Government of Sierra Leone, Ministry of Health and Sanitation: Health Sector performance report, January 2012. Sierra Leone: MoH;
• [56]Civil Society Health Forum, Fair Play for Africa, Women in Law Southern Africa, 2010 and Media Life: Making free health care work for all Zambians: Will this election deliver?. [http://www.oxfam.de/sites/www.oxfam.de/files/zambiahealthcareforwebfinal.pdf webcite] (accessed 15 March 2013)
• [57]The Observer: Why things fell apart for joined-up thinking. [http://www.guardian.co.uk/society/2006/feb/26/publicservices.politics webcite] (accessed 15 March 2013)
• [58]Meessen B, Hercot D, Noirhomme M, Ridde V, Tibouti A, Tashobya CK, Gilson L: Removing user fees I the health sector: a review of policy processes in six sub-Saharan African countries. Health Policy Plan 2011, 26:ii6-ii29.
• [59]McPake B: The globalisation of health sector reform policies: is 'lesson drawing’ part of the process? In Health Policy in a Globalising World. Edited by Lee K, Buse K, Fustukian S. Cambridge: Cambridge University Press; 2002.