User fees in health services in Nigeria: The health policy implications

摘要

There is widespread implementation of formal or informal user fees for health care in Nigeria. Quantitative and qualitative survey was conducted in various parts of eastern Nigeria to assess the impression of the Nigeria general public on the institution or abolition of user fees in health services. Of the total of 910 study participants, 520(57.1%) supported the institution of user fees while 390(42.9%) supported the abolition. Majority of study participants would prefer paying user fees if they are affordable and would guarantee efficient and quality service. The greater percentage of those advocating for abolition of user fees were the non-literate persons, the unemployed and the aged. If user fees are to be instituted, there is need for a mechanism that will provide some concessions such as appropriate systems of waivers and exemptions to these categories of individuals, so that no one is denied assess to basic health care. Introduction In most African countries including Nigeria, government budgets for social sectors have failed to keep up with population growth and demand; consequently, there is widespread implementation of formal or informal user fees for health care in government health systems. Their introduction was justified as a pragmatic solution to severe under-funding, as well as part of a broader ideological shift in health policy that emphasized efficiency [1]. However, international experience suggests that the case for reducing or removing official user fees for primary health services is strong. This is because, evidence from a broad range of developing countries including most parts of sub-Saharan Africa indicates that fees have rarely generated large amounts of revenue, are unlikely to have improved (and might even have worsened) allocative efficiency, and have too often disproportionately affected poor people [2]. Policy debate about user fees has been so contentious with proponents and detractors advancing their arguments often without recourse to the inputs from the general public. The objective of this study therefore was to seek the impression of the Nigeria general public on the institution or abolition of user fees in health services with the view to making the much needed system compatible with the goal of preserving equitable access to services. Methods Quantitative and qualitative survey was conducted in various parts of eastern Nigeria in March 2008 to assess the impression of the Nigeria general public on the institution or abolition of user fees in health services. Structured questionnaire and interview guides designed to reflect the various arguments advanced by proponents and detractors of user fees [3,4], were used for the survey. The survey was conducted at market places, schools, hospitals, along the street, wedding ceremonies, villages, commuter vehicles, homes etc. Consenting participants were of various occupations and educational background and aged 16-72 years old. Results Of the total of 910 study participants, 520(57.1%) supported the institution of user fees while 390(42.9%) supported the abolition (Table 1). Analysis based on occupation indicated that 62% of students advocated for user fees while 38% were against user fees. The corresponding figures for other categories were; civil servants: 70.4% vs. 29.6%; business class: 50.4% vs. 49.6%; unemployed: 29.5% vs. 70.5%. Chi-square analysis indicated a significant difference in the trend (χ 2 =40.2, P<0.05). Based on educational level, 36.9% of the non-literate persons supported user fees while 63.1% opposed user fees. In other educational categories the corresponding figures were; primary: 44.3% vs. 55.7%; secondary: 58.7% vs. 38.3%; tertiary: 66.5% vs. 33.5%. There was a significant difference in the trend (χ 2 =41.7, P<0.05) (Table 1). Based on age, 54.1% of those aged ≤18 advocated for user fees while 45.9% were against user fees. In other age categories the corresponding figures were; 19-30 years old: 60.9% vs. 39.1%; 31-40 y