Combined Methods Case study: Abolition of user fees in health units in Uganda

The Uganda Participatory Poverty Assessment Process (UPPAP) revealed the significance of health shocks on the vulnerability of the poor, particularly in rural areas. Addressing this popular concern, which had become a major election issue, in March 2001, the President of Uganda scrapped user fees for Government health units. Time series data on outpatient attendances showed that the combined effects of abolishing fees and increasing the supply of health services were dramatic, with an 84% increase in outpatient attendances between 2000/01 and 2002/03. Immunisation rates among children also increased dramatically (e.g. the proportion of children who received their third DPT immunisation increased from 48% to 84% between 2000/2001 and 2002/03). Although immunisations were supposed to be provided free before fees were abolished, the increase in immunisation rates can in part be attributed to the abolition of user fees. This is because most immunisations take place in health units, which people are now visiting in greater numbers due to the abolition of charging.

To confirm that the pick up in outpatient attendance was progressively weighted towards poorer households, the WHO/MoH conducted participatory research with carefully-sampled communities. A wealth ranking exercise conducted by villagers revealed that since the abolition of user fees, the poorest quartile has consistently used Government health centres more than any other group: in 2002 the poorest quartile used these facilities at a rate of 0.99 visits per person per year whereas for the wealthiest group the rate was 0.77. There is only limited data available for the period preceding the abolition of fees, but the average utilisation rate for the months of January and February 2001 was 0.52 and 0.42 respectively. Subsequent analysis of the 1999/2000 and the 2002/3 household surveys confirmed that poorer income groups had increased their utilisation of services more than richer groups. For hospital services, the rate of increase of consumption for the poorest two quartiles was double that of the richest group. The study concluded that this was a direct result of the abolition of user fees as 'the share of those who quoted cost reasons for not attending a hospital when sick decreased by about 20 percentage points in the bottom three quintiles but by much less for the top quintile' (Deininger and Mpuga 2004).

Hence through the careful sequencing of methods and data analysis, a strong picture emerged that abolishing user fees has made health care more accessible to poor people and consequently they have increased their consumption of these services.

In Uganda, health user fee exemption policies and community health insurance schemes have not helped the poor to prevent or manage the risk of ill health.ÿ Conversely, abolishing user fees has been an important social protection measure, indicating the need for this measure to receive much more attention in the social protection literature and debate. This has not been the case so far, however. The World Bank's flagship social protection strategy paper From Safety Net To Spring Board recognises both the drawbacks of community health insurance and fee exemptions.ÿ It notes that, in Sub Saharan Africa, the best way to manage risks is likely to be through strengthening basic health services.ÿ However, the strategy only advocates waiving fees for health care for poor people during an economic crisis. This fails to recognise that ill health is often a crisis for poor people and one that occurs repeatedly, driving them into poverty. It also fails to recognise the extent to which fees are likely to be suppressing demand for health services by the poor. The Ugandan Government's decision to abolish fees and largely to reject household financing mechanisms for public services also points to the need for the GoU health budget to be increased considerably if services are going to meet rising demands.

Source: Yates (2004)