User fee increase in improved community health fund

Abstract

Background: Evidence shows that introduction or user fee increase not coupled with improvements in quality of services triggers diverse coping strategies that result in substantial decline in services utilization. Previous studies focused on the impacts of user fees mainly on utilization of health services and the illnesses-related coping strategies. Little is known on how user fees increase would trigger full range of coping mechanisms in the Tanzanian context. This study explored community participation in decision to increase user fees and the mechanisms to cope with the user fee increase.

Objectives: To explore community participation and coping mechanisms in respect to user fees increase in the improved CHF.

Materials and Methods: A descriptive cross-sectional study using qualitative approach was conducted in Kondoa district Council. Study population was community members, health managers, local community leaders, in-charges of health facilities and relatives of admitted patients. FGDs, IDI and document reviews were employed to foster triangulation of the findings. A total of 33 participants were recruited (23 participants from FGDs, 10 from IDI). FGDs and IDI guides were used to collect data. Special designed forms were used to collect OPD attendance data for document reviews. Qualitative data were analyzed using thematic analysis approach. Inductive approach was used to identify themes as they emerge from the data. The data were analyzed manually through reading and re-reading the transcripts until the content was clear.

Results: This study found that the community was not involved in decision to increase user fees; the decision lacked community ownership, and it was a ‘’top-down’’ order. Regarding strategies to cope with increased user fees; poor people embarked on cost prevention strategies, which in its extreme were marked with complete neglect of treatment, leaving everything to God’s mercy, signifying hopelessness. Others resorted to self-treatment consuming herbals yet others delayed treatment, waiting for spontaneous recovery. Cost management strategies took the form of borrowing, selling assets, some of which with survival value to households like farms/lands and cereals signaling catastrophic health spending and deepening poverty. The study also found a reduction in health services utilization following user fees increase. Waivers as a protection for the poor against social exclusion were virtually inaccessible especially by the poor. There was a modest increase in enrolments in iCHF following user fees increase. Conclusion: Community did not participate in the decision to increase user fees and this was linked to poor enrolments in iCHF. Generally, raising user fees as a standalone strategy to accelerate enrolments in improved CHF (iCHF) did not adequately work and came with a heavy price tag of reduction in utilization of health services that offsets any potential benefits. Manipulation of user fees to accelerate enrolments in CHF has to be balanced with strategies that improve accessibility to waivers to protect the poor and vulnerable people. Recommendation: Kondoa district council should give community participation a due priority in activities targeting the community for the realization of envisaged goals. Further, it should identify the poor and give subsidized CHF ID cards similar to those of the paying counterparts. Kondoa district Council should consider going back to usual user fees for the sake of safeguarding the accessibility of the poor to health services. The Government of the United Republic of Tanzania through the MoHCDGEC and PO-RALG should consider making CHF mandatory using the iCHF model to attain UHC. More studies are needed to establish whether the observed decline in services utilization was due to user fees increase.