While in the midst of parliamentary and presidential elections here in Zambia, I want to use this post to bring broader international attention to our joint NGO ‘Vote Health For All’ campaign and some of the issues we raise in our new policy brief – Making free health care work for all Zambians: Will this election deliver?
A recent evaluation suggests that five years of free health care has done little to improve access to services for rural Zambians. While use of facilities increased by an impressive 55% when fees were first removed, this increase has not been sustained over time. Some commentators will undoubtedly use the evaluation to claim that Zambia’s ‘free health care experiment’ has been a resounding failure and should be abandoned. But with one of the highest maternal mortality rates in the world, rising inequality and urban poverty, and continuing barriers to access such as long distances to health facilities, abandoning free care in Zambia is just not an option. A closer look at the evaluation also raises some serious questions as to whether free care itself is the problem or rather how it was implemented.
Firstly, it’s difficult to conclude that free care had no impact on numbers seeking care when in many facilities, although fees were reduced (by an average of 51% in hospitals and 31% in health centres) they were not actually removed. Even after the policy was introduced up to a third of people in rural areas continued to pay out of pocket when they received treatment. In a country where half the population cannot meet basic needs even modest fees represent a major barrier for the very poor. To suggest that fee removal has not worked when in practice people are still paying for treatment would therefore be misleading.
Secondly, few of the now well understood necessary steps for successful fee removal have been taken.[i] When the Zambian President announced the policy change in January 2006, he committed to abolish user fees in all government and mission-run facilities in rural districts from April 2006. This allowed just three months for planning and communication. When the policy came into effect, lack of resources including drugs, staff and additional funding seriously compromised the ability of facilities to meet the needs of patients. Additional health workers were not deployed to rural areas and steps were not taken to mitigate the impact on staff.[ii] Measures were not taken to reduce the risk of drug stock-outs and in the first year 60% of essential drugs were unavailable. To make matters worse, many health facilities experienced a loss of income. While the loss of user fee revenue was due to be compensated – through a UK DFID replacement grant – in practice problems with disbursement meant that many districts had still not received the grant several months after the policy change. But user fee removal wasn’t the only reason for a drop in resources – between 2004 and 2006 there was a large reduction in district non-wage and district drug expenditure (down by 13% and 34% respectively). Overall, quality of health care suffered and patients faced longer waiting times, fewer drugs, and overworked staff.
Should the free health care policy be abandoned? I would argue that while the obstacles to successful implementation are formidable they can and must be overcome. The issues identified in the evaluation should be urgently addressed by the Government of Zambia with aligned support from development partners. Free health care must be made to work – continuing user fees puts lifesaving treatment out of reach for the poorest and most vulnerable people. If the right steps are taken free health care for all is both possible and affordable in Zambia. With the 2011 general election literally round the corner, the time is ripe for political leaders to step up to the challenge and make free health care work for all Zambians.
Felix Mwanza is the National Coordinator of Treatment, Advocacy and Literacy Campaign (TALC), a membership organisation which lobbies for equitable and sustainable access to affordable, quality HIV treatment, support and care in Zambia.
‘Vote Health for All’ is a coalition campaign whose members include: Civil Society Health Forum, Fair Play for Africa, Women in Law Southern Africa, 2410, Media Life, and Oxfam.
[i] For example, in the original terms of reference for the User Fee Removal Committee, budget proposals were to be prepared to meet the costs of an anticipated increase in demand for free services, including the procurement of additional drugs and recruitment and deployment of more health workers to rural areas. However, these proposals were never finalised. For a fuller discussion of the necessary steps for successful fee removal see Save the Children UK (2008) ‘Freeing Up Health Care: A guide to removing user fees’
[ii] Staff bonuses (typically 10% of fees raised) were scrapped and health workers faced an increased workload as demand rose. This led to high levels of dissatisfaction among health workers.
 Carasso, B et al. (2010) ‘Evaluating the impact of abolishing user fees in Zambia – summary of findings’ LSHTM, UZAM, UCT, MoH Zambia
 Lagarde, M (2010) ‘ Analysis of the impact of user fee removal on health seeking behaviours using a difference-in-differences approach’ LSHTM, UZAM, UCT, MoH Zambia
 Zambia Ministry of Health (2007) Health Sector Joint Annual Review Report 2006. Lusaka, GRZ