The effects of user fees on quality and utilization of primary care services in Afghanistan
Upcoming SlideShare
Loading in...5

The effects of user fees on quality and utilization of primary care services in Afghanistan



The effects of user fees on quality and utilization of primary care services in Afghanistan ...

The effects of user fees on quality and utilization of primary care services in Afghanistan

Presented at the International Health Economics Association meeting, Beijing, July 2009



Total Views
Views on SlideShare
Embed Views



2 Embeds 22 21 1


Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
Post Comment
Edit your comment
  • - Most NGOs were charging for services/consultations, and about half of BPHS facilities charged for medications as well Fee types, levels and exemptions/waivers not standardized Average per-visit fee in 2007 at BPHS facilities: 12.8 Afghanis ~= $0.25 US. - Official health financing policy not developed until 2007
  • - Free services considered an intervention, as the majority of facilities charged fees at baseline - Control facilities not “controls” in the typical sense in that fee types and levels – and whether facilities even charged fees! – were not standardized at baseline.
  • - Fee for services and separate charge for medications prescribed (% wholesale price) - Standardized levels proposed; final levels selected by user fee committee of staff and community members within range, depending on catchment area characteristics and other factors
  • Total of 47 pilot facilities Most pilot facilities were BHCs or CHCs (not too much difference between the two) Whenever possible, district hospitals near one of the user fee facilities were also included in the user fee arm to send consistent price signals to consumers (n=6 across 10 provinces) DHs are analyzed separately b/c they’re only in the user fee arm and are very different from BHCs/CHCs
  • Some facilities (n=6) had to be dropped at follow-up for facility assessment/patient exit interviews, and some (not all overlapping) had to be dropped for the catchment area surveys (n=6).
  • DD Linear regression used for continuous outcomes (e.g., observed and perceived quality, # OPD visits pre- and post); logistic DD regression models used for binary outcomes (perceived affordability (Y/N); % seeking first at pilot facility) Despite randomization, differences by study group at baseline in terms of: proportion HHs aware of facility; perceived affordability (HHs); % going first to pilot facility (Free services lower for all).
  • Observed quality of nearly all facilities improved from baseline to follow-up. Observed quality across 4 domains that should be sensitive to use of user fee revenues: 1) cleanliness and need for repairs; 2) drug availability; 3) equipment functionality; and 4) infrastructure. Free services facilities improved the most from baseline to follow-up. A series of progressively larger DD regression model showed that the increase between free services and user fee facilities was significant but when the effects of province and province over time were added to the model, the difference was no longer significant. Province had a much stronger effect.
  • Perceptions of quality based on summing 8 4-point Likert scale questions (range: 8 to 32). User fee and free services facilities increased significantly more than control facilities from baseline to follow-up, but the difference between the two was not significant. The effect of province over time on perceived quality of care was much stronger. Analysis of patient perceptions of quality showed no difference in improvement among any groups.
  • Not surprisingly, free services facilities showed the largest increased in perceived affordability from baseline to follow-up. FS facilities had significantly lower perceived affordability at baseline among households, perhaps b/c 80% charged fees, compared to 60% control facilities and only 50% UF facilities. DD logistic regression models showed that, adjusted for wealth, walking time to facility, and province, perceived affordability increased more in the free services arm compared to UF or control facilities, but this difference was not statistically significant. (District Hospitals showed a significant decrease in perceived affordability) Patient exit interviews showed similar results.
  • - Utilization increase greatest at Farah facilities that previously charged medication and service fees - Even when facilities in Farah province omitted from analysis, utilization increase still greatest at Free facilities: 53% compared to 17% at UF facilities and 29% at control facilities
  • Despite randomization, catchment areas of free services facilities different; on average, wealthier and more likely to use private sector services
  • - Average utilization, according to HMIS, in Afghanistan was <1 visit per capita per year in 2007: Low Utilization Setting. - More important to increase access to and use of care at this point among the population
  • OVERALL POINT: Starting point (whether facility charged fees previously) matters User fee facilities with no previous fees increased significantly less from baseline to follow-up than control facilities (298 visits/month on average less, p=0.03) Free services facilities that were free to begin with increased significantly more than any of the control facilities (by 688 visits/month more, p=0.05) and the user fee facilities that were free to begin with (by 985 visits/month more, p=0.007). Whether facilities charged a medication fee prior to the pilots had a large impact on subsequent use: User fee facilities that previously charged service and medications fees increased significantly more than those that were free previously (by 592 visits/month on average, p=0.03). Massive increases among Free services facilities that previously charged service and medications fees, compared to free service facilities without medications fees, as well as compared to all control facilities and all user fee facilities (p<0.01).

The effects of user fees on quality and utilization of primary care services in Afghanistan The effects of user fees on quality and utilization of primary care services in Afghanistan Presentation Transcript

  • The effects of user fees on quality and utilization of primary care services in Afghanistan Laura Steinhardt, David Peters, Sahibullah Alam, Krishna Rao, Peter Hansen July 15, 2009
  • Background I
    • Rapid rebuilding of health care infrastructure in Afghanistan since 2001
    • Development of Basic Package of Health Services (BPHS) for primary care
      • BPHS delivery contracted to NGOs in most provinces
      • Vastly expanded access to BPHS services from 2001-present
    • BPHS heavily donor-dependent
      • Reliant for nearly all BPHS services on 3 major donors
      • Funded at ~$2 US to $5 US per capita (avg.= $4)
  • Background II
    • No standard guidelines on cost sharing
    • Most BPHS facilities charged some type of fees
    • Little evidence from post-conflict settings on effects of fees on revenues, quality and utilization
    Source: National Health Services Performance Assessment (NHSPA) facility surveys, 2004-2007. View slide
  • Health financing pilot objectives and description
    • Objectives: Evaluate different community financing mechanisms on ability to:
        • Improve quality of care
        • Increase financial access to care
        • Raise revenue for health sector
        • Enhance community ownership
    • Pilot types:
        • User fees (standard fee for services and for drugs)
        • Community health fund (voluntary pre-payment scheme)
        • Free services
        • Control facilities (continued current cost sharing scheme – 60% charged fees at baseline)
    View slide
  • User fee pilot description
    • Average visit fee: 11.5 Afs (~ $0.23 US)
      • Service fee: 2-7 Afs.
      • Drug charge: 10-50% wholesale price
    • Fees retained at facility
      • Managed by user fee subcommittee
      • Used to make quality improvements (small repairs, drug purchases, improve infrastructure)
    • Waiver card system for very poor and female-headed households
      • Community leaders identified poor in each village
    • All preventive, promotive care free*
    * Includes EPI, well-baby visits, ANC, deliveries, family planning and TB care and emergencies.
    • Quasi-experimental pre/post design
    • Pilots implemented in 10 provinces (7 managed by NGOs, 3 by MoPH)
    • 5-6 facilities eligible in each province
    • 2 of 3 interventions implemented/province
    • Facilities randomized within provinces
    • Piloted from 2005-2007
    Design of health financing pilots Province 1 Facility 1 Facility 5 Facility 4 Facility 3 Facility 2 n=27 n=10 n=10 Free Services User Fees Control
  • Evaluation data sources
    • Pre/post facility assessments
    • Pre/post patient exit interviews
    • Pre/post catchment area surveys
    • Health Management Information System (HMIS) utilization data
    • In-depth interviews with:
      • Facility staff
      • Community leaders
  • Evaluation analytic methods
    • Construction of observed and perceived quality scales from binary and Likert-scale questions
    • Despite randomization of facilities within provinces, differences across provinces in:
      • Managing service provider (NGO)
      • Baseline fee levels
    • Difference-in-Difference (DD) cross-tabs and regression models used, where appropriate
    • Line-by-line coding of key themes in qualitative transcripts
  • Results – observed quality of care +6.4 +5.8 +12.1 +8.3 Note: Each line represents one facility.
  • Difference-in-difference linear regression of perceived quality, among households
  • Percent of households rating facility as affordable Notes: Affordability efined as 3 or 4 on Likert-scale question: “The cost of the facility is reasonable” (3=agree; 4=strongly agree). Perceived affordability significantly lower at Free Services facilities at baseline (p<0.05). The only significant change in affordability (from DD logistic regression, adjusted for province, wealth, and walking time) was for User Fee-District Hospitals (p<0.01).
  • Results – staff and community leaders’ thoughts on quality and affordability
    • Important sources of discretionary income
      • Allows greater autonomy in day-to-day functioning
    • Wide variations in percent of revenues spent and what they were spent on across user fee facilities
      • Drugs to prevent stock-outs
      • Infrastructure upgrades (female waiting room, heaters)
      • Small staff incentives (<10% revenues)
    • User fees generally affordable by all, but exceptions at a few facilities
      • In Badghis province, patients w/o waiver cards had to borrow from shopkeepers to pay fees
    Source: In-depth interviews.
  • Change in average monthly OPD visits, one year pre- vs. one year post Source: HMIS data. +102% +11% +22% +33% +52%
  • Percent of sick household members seeking care first from pilot facility* * Among those seeking care Note: Lower % at free facilities seek care first at pilot facility at baseline (p<0.05); No significant change over time, by study group, adjusted for province, walking time, age, sex, wealth, and illness type. Source: Baseline and follow-up Catchment area surveys.
  • Results – staff and community leaders’ thoughts on utilization
    • Free services are good for patients (increased access) but bad for facilities (overcrowding)
      • Now mildly ill or non-patients come for care
      • Less staff time and drugs left for “real patients”
    • When there are fees, “only the real patients come”
    • Patients value medicines more when they pay for them
  • Summary of results of user fees
    • No differential effect on quality (observed or perceived)
    • Generally considered affordable, but not always by the poorest
    • Staff positive about fees
      • Revenues useful for making real-time repairs
      • Fees decrease patient loads
    • Suppressive effect on curative care utilization
      • Large rise in visits when fees removed
      • Stronger effects of medication fees than service fees
  • Conclusions
    • Fees have few beneficial effects in rapidly changing post-conflict setting
    • Other factors, such as regular performance monitoring (Balanced Scorecard), may have greater impacts on quality
    • Fees – even at nominal levels – reduce access to care
      • Removing all barriers to access important in low-utilization, post-conflict settings
    • Limited revenues raised (average = 3.6% facility operating costs), but important source of discretionary income
  • Policy results and recommendations
    • Ministry of Public Health banned user fees at BPHS facilities in 2008
      • Visits increased by 13% in following 3 months
    • In light of blanket policy decision, need to consider:
      • Flexibility for BPHS providers to increase staffing, funding, at facilities
      • Possible alternative mechanisms for discretionary funds at facilities
      • Continued monitoring to ensure no unintended consequences or under-the-table payments
  • Thank you
    • Acknowledgments: Ministry of Public Health, Kabul, Afghanistan; Johns Hopkins University, Kabul, Afghanistan; Future Health Systems ( )
    • Author contact info: Laura Steinhardt: [email_address]
    • David Peters: [email_address]
    • Sahibullah Alam: [email_address]
    • Krishna Rao: [email_address]
    • Peter Hansen: [email_address]
  • Additional Slides
  • Difference-in-difference linear regression of average monthly OPD visits, pre- vs. post Model uses Huber-White robust standard errors (White 1980). Data on up to 10 additional non-pilot facilities/province added to control group to yield N=98 facilities at baseline (one year pre-HFP) and N=98 at follow-up (one year post-HFP). Source: HMIS data.
    • Free facilities increase the most, but
    • Starting fee levels matter
    • Prior medication fees have large impacts on subsequent use
    • Facilities randomized to free services that had prior service and drug fees had huge increases after fees removed
  • Table 1: Baseline study groups