A nutrition clinic during 2009 in CÃ´te d’Ivoire saw only 33% of the number of clients it helped in 2007.Â IRIN reports that staff believe this was not due to decreases in malnutrition, but to the introduction of user fees. “Under the hospitalâ€™s cost-recovery scheme, each family must pay 5,000 CFA francs (US$10.80) per child requiring intensive therapeutic feeding.”
MÃ©decins Sans FrontiÃ¨res used to run the nutrition clinic, but fees were needed to run the service after the NGO left in 2008. “Many women who come in cannot afford to pay, Konan (who runs the clinic) said. ‘Two out of six new cases we have now could not payâ€¦ Sustaining these activities is hard â€¦ MSF wanted us to make the treatment free but we need more money to do so.'”
Cost recovery schemes have been touted, at least since the 1987 Bamako Initiative, as a way to guarantee that primary care services are sustainable. Mali, where the Bamako Initiative was penned, has been running a cost recovery system for many years that involves the community in decisions about the costs of medicines in the community health center, but ethical issues continually arise when malaria medicines are supposedly free through money from sources like the Global Fund.
A study in Burkina Faso on fees in a Bamako Initiative style program found that, “The introduction of fees-for-services had an adverse effect on service utilization. The study district is in a position to bear the financial cost of taking care of the poor and theÂ community is able to identify such people. Incentivesmust be introduced by the state and be swiftly applied so that the communities agree to a more equitable system and thereby allow access to care for those excluded from services because they are unable to pay.”
Our experience in Akwa Ibom State, Nigeria, attest to the negative impact of fees. Each local government decides on its own scale of registration fees for antenatal care.Â While ANC registration in southern Nigeria is generally high, we found that only about 20% of pregnant women were coming to government run ANC clinics in Akwa Ibom.
After introducing a program to enhance malaria in pregnancy control services in selected local governments, we found that attendance still remained low.Â The community distributors we had trained were expected to refer pregnant women to ANC, but the process was thwarted when the women were asked to pay between 200-300 Naira (upwards to US $2) to register.
Fortunately the women were able to receive their Intermittent Preventive Treatment (IPT), health education and some bednets through the trained community distributors, but the goal of linking them to improved quality comprehensive ANC services could not easily be met.
Advocacy efforts continue with each of the local government chairpersons and councils in the project area, but they are reluctant to relinquish these small fees. The state health services, such as secondary level district hospitals, offer free ANC, but this bypasses the primary care system. At any rate there are not enough state hospitals to make up for the need.
The State Legislature continues to debate whether to make health care for women and children free throughout all local governments. In the meantime, women in the state are effectively denied the means to protect themselves and their unborn children from the risks of malaria.
Much work is still needed to overcome the barriers to universal coverage of malaria interventions. The goals of sustaining a health system and eliminating malaria appear at odds at times, but delivery of malaria services depends on a strong primary health care system.Â There are certainly better sources of revenue for health services than charging fees to poor pregnant women in communities where people earn less than a dollar a day.