Research article

Maintaining quality of health services after abolition of user fees: A Uganda case study

Juliet Nabyonga-Orem¹ , Humphrey Karamagi² , Lynn Atuyambe³ , Fred Bagenda⁴ , Sam A Okuonzi⁵ and Oladapo Walker⁶

¹Health systems unit, World Health Organization, Kampala, Uganda

²Health systems unit, World Health Organization, Nairobi, Kenya

³Department of community health and behavioral science; School of public health – Makerere University; Kampala, Uganda

⁴Department of community medicine, Mbarara University of Science and Technology, Mbarara, Uganda

⁵Regional Centre for Quality of Health Care; School of public health – Makerere University; Kampala, Uganda

⁶Department of Technical cooperation, World Health Organization – Regional office for Africa, Brazzaville, Republic of the Congo

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BMC Health Services Research 2008, 8:102doi:10.1186/1472-6963-8-102

Published:	9 May 2008

Abstract

Background

It has been argued that quality improvements that result from user charges reduce their negative impact on utilization especially of the poor. In Uganda, because there was no concrete evidence for improvements in quality of care following the introduction of user charges, the government abolished user fees in all public health units on 1^st March 2001. This gave us the opportunity to prospectively study how different aspects of quality of care change, as a country changes its health financing options from user charges to free services, in a developing country setting. The outcome of the study may then provide insights into policy actions to maintain quality of care following removal of user fees.

Methods

A population cohort and representative health facilities were studied longitudinally over 3 years after the abolition of user fees. Quantitative and qualitative methods were used to obtain data. Parameters evaluated in relation to quality of care included availability of drugs and supplies and; health worker variables.

Results

Different quality variables assessed showed that interventions that were put in place were able to maintain, or improve the technical quality of services. There were significant increases in utilization of services, average drug quantities and stock out days improved, and communities reported health workers to be hardworking, good and dedicated to their work to mention but a few. Communities were more appreciative of the services, though expectations were lower. However, health workers felt they were not adequately motivated given the increased workload.

Conclusion

The levels of technical quality of care attained in a system with user fees can be maintained, or even improved without the fees through adoption of basic, sustainable system modifications that are within the reach of developing countries. However, a trade-off between residual perceptions of reduced service quality, and the welfare gains from removal of user fees should guide such a policy change.