Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK.
J Health Serv Res Policy. 2012 Jan;17(1):30-6. doi: 10.1258/jhsrp.2011.010166. Epub 2011 Nov 17.
This study aims to overcome some of the limitations of previous studies investigating the effects of fee removal, by looking at heterogeneity of effects within countries and over time, as well as the existence of spill-over effects on groups not targeted by the policy change.
Using routine district health services data before and after recent abolitions of user charges in Zambia and Niger, we examine the effects of the policy change on the use of health services by different groups and over time, using an interrupted timeseries design.
Removing user fees for primary health care services in rural districts in Zambia and for children over five years old in Niger increased use of services by the targeted groups. The impact of the policy change differed widely across districts, ranging from +12% and +194% in Niger to -39% and +108% in Zambia. Eighteen months after the policy change, some of these effects had been eroded. There was evidence that abolishing user fees can both have positive and negative spillover effects.
These results highlight the importance of paying attention to implementation challenges and monitoring the effects of policy reforms which are often more mixed and complicated that they appear. The comparison of these reforms in two countries also sheds light on the potentially different ways in which free care can be used as a tool to improve access.
本研究旨在克服以往研究在考察费用减免效果方面的一些局限性，从国家内部和时间上的效果异质性以及政策变化对未受政策影响人群的溢出效应等方面进行研究。
利用赞比亚和尼日尔最近取消用户收费政策前后的常规地区卫生服务数据，我们采用中断时间序列设计，考察政策变化对不同人群和不同时间使用卫生服务的影响。
取消赞比亚农村地区基本医疗服务和尼日尔五岁以上儿童的用户收费增加了目标人群对服务的使用。政策变化的影响在不同地区差异很大，在尼日尔的增幅为+12%和+194%，在赞比亚的降幅为-39%和+108%。政策变化 18 个月后，其中一些影响已经减弱。有证据表明，取消用户收费既可以产生积极的溢出效应，也可以产生消极的溢出效应。
这些结果强调了关注实施挑战和监测政策改革效果的重要性，因为这些效果往往比表面上更加复杂和多样化。对这两个国家的改革进行比较，也揭示了免费医疗作为改善可及性的一种手段可能具有不同的应用方式。
