Does increase in utilisation rates alone indicate the success of a user fee removal policy? A qualitative case study from Zambia

ObjectiveTo provide more comprehensive understanding of utilisation of health facilities in the context of user fee removal policy with a focus on local practices.MethodsA wide range of stakeholders were included in in-depth interviews, group discussions and observations at sites where user fees had been removed and those still charging.ResultsSuccess of a user fee removal policy is typically measured in terms of utilisation. The focus of this study was on the local context of attendance rather than statistical trends. The results show that even after removal of user fees ill people were denied health care due to known barriers of distance, staff attitudes, waiting times and additional costs. Frivolous use and sharing of medicines in the community further compromised the success of the user fee removal policy.ConclusionUtilisation rates as a statistical indicator are not sufficient to assess the success or failure of user fee policies in improving health outcomes. Qualitative insight into local health care practices is required to understand how (removal of) user fees affect both individuals and communities. Further research in remaining barriers to access, frivolous use, treatment and adherence to medical advice is required.