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HEALTH POLICY AND PLANNING; 17(3): 273–280
© Oxford University Press 2002
Paying for reproductive health services in Bangladesh: intersections between cost, quality and culture SIDNEY RUTH SCHULER,1 LISA M BATES2 AND MD. KHAIRUL ISLAM3 1JSI Research and Training Institute, Arlington, VA, USA, 2Harvard University School of Public Health, Boston, MA, USA and 3PLAN International, Dhaka, Bangladesh In 1997 a consortium of non-governmental organizations (NGOs) in Bangladesh began to implement health sector reform measures intended to expand access to and improve the quality of family planning and other basic health services. The new service delivery model entails higher costs for clients and requires that they take greater initiative. Clients have to travel further to get certain services, and they have to pay more for them than they did under the previous door-to-door family planning model. This paper is based on findings from a qualitative study looking at client and community reactions to the programme changes. It examines a number of barriers to access and constraints to cost recovery, including gender, class and ideas about entitlements, the role of government and obligations among people. The NGOs want to maximize cost recovery while making the basic services they offer accessible to most people. The findings suggest that this requires more than the establishment of an appropriate pricing structure. Attitudes related to charging and paying for services must also change, along with the institutional policies and practices that support them. Key words: health care reform, user fees, NGOs, reproductive health, gender, culture, ability to pay, willingness to pay, cost recovery, Bangladesh
Introduction The public provision of health and family planning services to the poor at no charge (or for a nominal cost) is common in low-income countries. Policy-makers, providers and clients alike tend to agree that the quality of these highly subsidized services is inadequate. And because free services and health commodities are often under-funded, and therefore insufficient to meet demand, they are vulnerable to informal gatekeepers who collect unofficial charges (Saha and Bartlema 1998: 160). Policy-makers often view cost recovery as a necessary component in improving the quality and financial sustainability of services. The client should have greater rights and ability to demand higher quality if he or she is ‘the payer’ or ‘partial payer’, at least in theory. Even the poor may benefit from a system in which they are required to pay more if the system becomes more predictable and transparent, and their decisions about service utilization are based on better information. Various studies suggest that willingness to pay is contingent on the perceived quality of the services and may be enhanced by introducing quality improvements (Litvack and Bodart 1993; Yazbeck 1995; Alderman and Lavy 1996; Hotchkiss et al. 1998; Hardee and Smith 2000). However, in many societies, the idea that the poor are entitled to free services is common, and introducing charges for services or commodities (like contraceptives or medications) that were previously free or available for a token payment is no simple matter. In cases where utilization of basic services declined following the introduction or augmentation of fees, it is often not clear
from the literature to what extent these declines were due to clients’ inability to pay as opposed to their unwillingness to pay based on their perceptions of service quality (Hotchkiss 1998). If it is true that, in many settings, improving service quality prevents a drop in utilization when prices are raised, then it becomes essential to understand what constitutes quality from client perspectives. In 1997 the Bangladesh Government issued a new Health and Population Sector Strategy. The Strategy calls for various reforms, including greater integration of family planning with health, a focus on users of services rather than demographic targets, improved quality of care and a wider range of reproductive health services, with increased attention to maternal and adolescent health care, provided as part of an ‘essential services package’ (ESP). A consortium of non-governmental organizations (NGOs) supported by the US Agency for International Development (USAID) has moved ahead of the government in implementing the ESP approach. The NGOs have discontinued or cut back door-to-door contraceptive distribution in favour of offering a wider range of services through clinics and satellite clinics, with village depots for re-supplying contraceptives in rural areas. The NGOs have also invested in technical and management training, instituted standards and protocols, and made physical improvements to the clinics. Users are being charged modest fees for these services, many of which used to be provided free of charge or at lower cost, and some of which (mainly contraceptives) used to be delivered to their homes. The higher quality and greater range of services available from the NGOs are intended to attract clients and increase the health impact of services. But for this to happen, the intended users must be willing and able to take more initiative and to bear
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the added costs – the direct charges for services and commodities, as well as the monetary, psychological and (for some) social costs of accessing them. Research conducted prior to the programme change had provided some evidence that it would be possible to institute modest increases in fees for contraceptives and maternal and child health (MCH) services without undermining utilization (Quayyum et al. 1997a, b; Levin et al. 1999; Routh et al. 2000). Based on this evidence, the NGOs set initial prices which were to be adjusted later, if necessary, based on experience and on findings from additional studies that were underway. The NGOs work in areas allocated to them by the Bangladesh government; thus they have instituted user charges (albeit not consistently) for services that are available for free at clinics and satellite clinics in other jurisdictions, in some cases nearby. The NGOs’ ability to attract clients may depend to a large extent on their ability to provide higher quality services than those the public sector provides. This paper presents community and client perspectives regarding service quality and user charges for basic family health services in urban and rural areas of Bangladesh. It discusses factors influencing both ability and willingness to pay for services, such as poverty and gender inequality, but also ideas about the role of government, and the influence of past and present policies. The findings come from a multimethod, qualitative study assessing the effects of the new NGO service delivery strategies on patterns of utilization, client-provider relations, client satisfaction, and householdlevel decision-making about family planning and other reproductive health services.
Data sources The sites were two urban and three rural areas where the transition from home to clinic-based services was underway, and one area where household delivery of contraceptives was still in effect under the government’s management. The NGO sites were selected in collaboration with USAID and the NGO consortium, and were considered average in terms of performance. Within the five NGO sites, data collection was focused in two to three sub-areas, one within a 1-mile radius of the clinic, and one to two between 2–4 miles away, where satellite clinics were regularly held. Both users and non-users of the NGO services were asked about their experiences and perceptions of the range of service providers available, including but not limited to the NGOs implementing the new service delivery model. The data were collected by five female and two male field researchers who were experienced and well trained in qualitative methods. Teams of two to four researchers made multiple visits of 2–3 weeks to each site between January 1998 and July 2000. Respondents were asked about their experiences prior to policy changes as well as recent experiences. Both open- and closed-ended questions were used. Criteria for assessing quality of services were ascertained from spontaneous comments about their experiences with various types of providers and decision-making regarding the use of various
health services. Direct questions about specific dimensions of quality were also asked of recent clients (e.g. general ambience and cleanliness of the facility, the range of services provided, privacy, technical competence of staff, content and tone of communication with clients). This paper is based on approximately 500 transcripts from in-depth, semi-structured interviews, 30 of which were group discussions. In addition, researchers’ unstructured ethnographic field notes were collected and analyzed. Respondents were identified through both convenience and purposive sampling, using the ‘snowball’ method, key informants and service records. Although random procedures were not used, efforts were made to ensure representation of key population subgroups, including individuals who had never used the NGO services. The researchers used an ethnographic database program in thematic coding.
Quality and willingness to pay In Bangladesh the poor are known to spend money on various sources of health care, including traditional practitioners, pharmacies and non-accredited village doctors. Even in government facilities where services are officially available for free, charges are often collected informally (Government of Bangladesh 1999; Killingsworth 1999).1 Thus, one might assume that most poor people would be willing and able to pay a modest charge for basic services in NGO clinics if they perceive the services to be of adequate quality. Our study findings generally confirmed that people are prepared to travel further and pay more for higher quality services and that NGOs are effectively addressing key aspects of quality that clients value. Paramount among these is the interpersonal dimension of quality – treating clients kindly, tactfully and with respect, whether poor or comparatively better off (Bates et al. 2000; Schuler et al. 2000). The primacy of client–provider communication in client assessments of quality has been documented in many other studies worldwide (Gallen and Lettenmaier 1987; Raymundo and Cruz 1993; Haddad and Fournier 1995; Murphy 2000). But, not surprisingly, respondents in our study were not always willing to pay for a particular service, nor equally disposed to pay for all types of services, and this fact may have wider implications than the designers of the new strategy anticipated. Our findings suggest that poor people’s willingness to pay for health and family planning services is best understood in the context of their health-seeking strategies and the cost–benefit calculations that they commonly employ. Gender inequality is one factor influencing these strategies and calculations. Another is the government’s past and present policies, in response to which people have formed certain ideas about the government’s agenda and its roles and responsibilities, particularly towards the poor. Notions about obligations among people, and the importance of looking out for one’s own, influence health-seeking strategies and willingness to pay insofar as people are unwilling to pay when they feel it is not right to charge them. These topics are explored below.
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Health-seeking strategies of the poor Reliance on free and low cost services Interview findings suggest that poor families tend to make significant expenditures for health only in the context of health problems seen as life-threatening or problems that interfere with the family’s ability to generate income. “Many people need to go to the hospital but don’t. They sit and wait for their diseases to get worse,” said a middle-aged mother of six in one of the rural sites. When they do seek health services, many people reported sacrificing considerable time and effort to get them for free or at the lowest possible cost. Some had travelled long distances, often on foot, undergone long waits in crowded government facilities and gone to a variety of different places (including but not limited to government facilities) for different health needs in order to get services and commodities at the lowest cost. The findings also show that many of the poorest have long been dependent on the government for reproductive and other health services. Low-income respondents described many limitations of the government health system, but also made it clear that they were grateful to get free or nominally priced health care even if obtaining it was difficult or unpleasant. Unwillingness to spend on women’s health care Social restrictions on women’s mobility appear to have relaxed considerably. In all six study areas, it had become quite common for women to go to clinics for family planning and other preventive and minor curative care, for themselves and their children. (The data suggest that women’s increased ability to go to health facilities is a consequence of economic opportunities that have drawn women into the public sphere as well as widespread acceptance of family planning and other preventive health measures – two trends amply documented throughout the country.) But families are often unwilling to spend much on preventive care and treatment for women. Because of gender inequality and women’s exclusion from many types of wage employment, the threshold for defining a health crisis tends to be high for women. “They tell their wives to disregard it since it is already there and the family’s work is still getting done,” said one rural woman resignedly. A man told the researchers that he used to get angry when his wife went out of the house by herself. He no longer cared about that, he explained, but he did not want to have to spend what little money he had on his wife, and that is why he didn’t like her going to doctors. Another man, an agricultural wage labourer without any education, said defensively: “I can’t manage to provide food properly so how will I manage medical treatment for my wife? She has a father and a brother – let them take care of it!” Men’s reluctance to spend money on their wives’ health care extends to family planning as well. Compared to research from a number of years ago (Schuler et al. 1996), our findings suggest that men’s appreciation of the importance of fertility
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control for their family’s welfare has increased. Yet they remain reluctant to pay much for it. One urban woman, who switched from oral contraceptives to contraceptive injections because of side effects, was warned by her husband: “you never know what type of problems may arise”, but he did not forbid her from using the method. When she then had menstrual problems, her husband became very angry and scolded her repeatedly, despite her own efforts to improve her condition by resuming pills. He refused to take her to a doctor, saying, “you have taken the injection, so you suffer”. Family planning continues to be considered a women’s concern, probably in part due to the targeting of women throughout the government’s fertility reduction programmes. Those interviewed often said that women were expected to bear their pain, especially in families living on very low incomes, and that they sometimes chose to do so rather than squander the family’s resources (as they saw it). Because they could not justify, to themselves or their families, the anticipated expenses of dealing with contraceptive side effects, women worried by their symptoms often discontinued using contraception or switched methods.
Power and personal relationships Poor respondents often relied on personal relationships to get access to health services or to get better services for a lower price. And the existence of a personal relationship often influenced the choice of provider as well as expectations about payment. That one is likely to receive poor treatment in health facilities without the intervention of a personal friend, relative or other advocate connected with the facility is a theme that recurred repeatedly in interviews about health care decision-making and utilization, and many women reported seeking these types of advocates.2 Indeed, many aspects of life in Bangladesh are shaped by patron–client relationships, and a poor person’s ability to get access to resources typically requires a link with someone more influential (see Hassan 1999). A recent study on unofficial payments in government health facilities found that the collection of such fees was ‘open to local restraint exerted through personal connections and patient/family reputation’ (Killingsworth 1999: 158).3 “Only the wealthy can get good health care” was a frequent lament among participants in our study, both in individual and group interviews. Respondents said that service providers would not dare to “misbehave” (by overcharging) those who were economically influential, and that the better off and more educated “know how to talk” with the service providers. The comparatively wealthy were also more likely to be personally acquainted with doctors or to have a kinship tie to them. A rural woman complained: “We [poor people] have to buy medicine but they [the rich] get two saline instead of one. If a rich woman comes they will take plenty of time to examine her, but I will not get any special favours. Probably they [the rich] are able to do something if they do not get good treatment. They will protest, saying that if the government hospital takes money [bribes] we will not go there for treatment . . . .
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Then they [the doctors] take care of them properly. But if we ask for medicine they say they have run out, and we should go out and buy it.” When faced with a health crisis the poor often appealed to better-off patrons in the community to help them arrange or pay for care. For example, a boy in one of the research villages had severe pain in his ear. His father took him to a district hospital, where they felt they were being ignored. After waiting a long time they left the health centre and called upon the son of a wealthy merchant who was a local political leader. The young man obliged by going with them to the hospital. According to the boy’s father, the man spoke forcefully to the doctor, instructing him to give the child proper care. The father was satisfied with the treatment they then received. Institutionalizing kindness and equity Our overall sense from interviews is that people generally do not expect kindness or respect from health service providers. Clients generally saw compassion towards the poor as an individual character trait, one that is highly valued but unrelated to job responsibilities. Some clients in the NGO clinics, by contrast, commented that the staff’s kind behaviour towards them was intended to attract them – that the staff have to be nice in order to build up a clientele and avoid clinic closure and the loss of their jobs. This attitude may signal an emerging ‘consumer awareness’ that, in the long run, could contribute to better quality of care by forcing providers to compete for clients amongst an increasing number of health care options available to rural and urban residents. Indeed, we were surprised to find that most users of NGO clinics said the staff treated everyone well, regardless of social status. For example, “I am on familiar terms with all of the staff because I have been there so many times, but I don’t think they do extra favours for me just because I am familiar. They treat me as they treat others. Whoever comes first is seen first. They see me according to my serial number. It doesn’t matter if someone is rich or poor, known or unknown to them.” (urban woman) “They treat you based on your illness. If you have a serious problem they may give you four sets of pills, and if it is minor, only two. It is not a question of rich or poor – rich and poor alike must buy a ticket, and it costs only 15 taka!” (rural mother of three)
Policies, norms and expectations Government’s role as health care provider Many of those interviewed conveyed a sense of resignation, saying that the poor generally lacked access to health care, but that little could be done to alter this. Others expressed feelings of indignation at the injustice of this situation, protesting that the government was failing to fulfill its
responsibility to the poor. This sense of entitlement was sometimes extended to NGO services as well, perhaps because reproductive health services provided by NGOs tend to be so similar to those provided by the government that many clients did not know the difference. (The NGOs’ adoption of the same green umbrella logo that the government uses to show that the ESP is available has probably contributed to this confusion.) An urban woman who worked as a vendor complained about the NGO service charges: “They used to provide treatment according to government policy [i.e. free of charge], but now they say ‘give me ten taka and I will examine you.’ ” The NGOs in this study are providing family planning and basic health services (the ESP) in geographic areas where the government has assigned them to work. In many of these areas, people are now obliged to pay for contraceptives and other essential services they previously received for free or at a lower cost. This was a less significant problem for women in the urban sites, where a variety of government, NGO and private sources of health care are available in relatively close proximity. In rural areas the transportation and time costs are more likely to limit the feasibility of going to a government facility to get free services, and some felt it was arbitrary and unfair that they should have to pay for what the government provided for free in neighbouring jurisdictions. One rural woman complained, “Where my mother lives they provide lots of medicine [without charge], but here [in the NGO clinic] they provide nothing, not even two tablets . . .” In some cases rural people who had travelled to government facilities were turned away and told to use the NGO services in their own administrative area. The government health staff may have been doing this to support the NGOs and their new programme, or to comply with the government’s system for tracking contraceptive distribution. In any case, the study respondents thought it was unfair, and they resented the way they were treated by government health staff. One woman, who had walked a long way to get free contraceptives, commented, “The apas [‘sisters’ – in this case health staff] seemed very angry with me. They asked me angrily, where do I live, why have I come, etc., etc. It wasn’t only me. A woman came from another village and they were asking her why she had left her village and come there. In the end they did not give that woman her injection. I felt really bad for her . . . . Doctors should not act that way. They should be cool tempered. They are not giving us their own things, they are giving things allocated by the government, and they are getting their salary from the government.” Psychological impact of fertility reduction policies In addition to free contraceptives and related services, the Ministry of Health and Family Planning has, for years, provided payments to people who adopt long-acting contraceptive methods (sterilization, IUDs and more recently Norplant) to compensate them for travel costs and forgone wages, which may make contraceptive use prohibitive for the very poor. Clients have come to expect compensation for using clinical methods even though they do so on their own volition and for their own benefit, making it difficult for the
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Paying for reproductive health services NGOs to charge clients, particularly for long-acting methods. Believing the government wants them to use contraceptives, some people feel that they should not have to pay for them or for treating side effects (Schuler et al. 2001). As a rural woman with five children commented: “When I need medicines for my menstruation which stopped because of taking the injection, they want money. Aren’t they supposed to give medicines free? It was caused by the injection!” Another woman having problems with contraceptive injections complained: “It was the same when I used to take pills (oral contraceptives). Then too the apas would say that they would give medicine for the physical weakness, but only if I paid for it. I say that if we have to give money, we should take it from [a private] doctor.” In other words, why pay money to those whose job it is to get women to accept family planning? Equation of health care with pharmaceuticals “I have paid the doctor just to talk to her about my illness . . . . They don’t give you medicine here. They don’t give medicine anywhere anymore, not even at the government hospital! All of the medicines are being sold outside [i.e. government supplies are sold illegally]. Nobody shows any compassion for the poor. I did not ask her for medicine because I had heard before that they did not provide [free] medicine . . . . It is senseless to write prescriptions for poor people like us. If we can’t buy the medicine then what good is a prescription?!” This woman’s outburst contains two important themes that emerged in all of the sites. One is poor people’s sense of entitlement to some level of health care and the frustration and resentment that result when they feel they are not receiving it. This frustration is illustrated in some of the remarks presented earlier, to the effect that providers are corrupt and prejudiced against the poor. The woman quoted here did not even ask for assistance in getting medications because she assumed her requests would be denied. Second is the tendency to equate healthcare with medication. Ironically, the same woman also praised the doctor’s treatment of her, showing that she valued the quality of her interpersonal exchange with health facility personnel. Yet, this aspect was overshadowed by the fact that the providers recommended a treatment that was beyond her reach. In interviews about health care utilization and decisionmaking, respondents from the poorest economic groups often said they preferred to go to government facilities because free medicine was available there. As a pregnant woman from the rural areas put it, “We are poor people. We will go wherever we can get medicine for the least amount of money.” Many people spoke of health clinics as if they were governmentsubsidized pharmacies where the diagnosis as well as the treatment is provided ‘over the counter’. For problems seen as relatively minor, including most reproductive health issues and common illnesses, what made one facility superior to another (from the client point of view) was whether drugs were available, and whether they could be obtained for free or at a nominal cost. The following quote from a field researcher suggests that both staff behaviour and clients’
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priorities are to blame for the equation of healthcare with the dispensing of medications: “Although there was a stool next to the paramedic for clients, no one felt it necessary to sit there. All the women were talking about their problems and the paramedic was giving out medicine accordingly. I saw [the client I was interviewing] standing beside the paramedic and telling her something. Without looking at the client, the paramedic gave her some tablets wrapped in paper and said something to her . . . . Within a minute [the client] emerged from the room smiling, and came over to talk with me . . . . Sometimes she had to return from the clinic without medicine, and often they gave very few pills but today she got more so she was happy, she told me. ‘The medicine of this clinic is very effective. We get good results from taking it. But there is a problem here. The [staff] do not come regularly and they do not provide the medicine properly’ she explained, ‘We hear that they sell the good medicines. They used to provide a whole packet of medicine for children’s fever and cough but now they divide it among five people.’ She explained the irregular attendance of the staff by saying, ‘If they come they have to provide medicine, and if they came every day their supply would run short.’” This comment also shows the common perception that getting drugs and vitamins from government facilities depends on the whim of clinic staff, which women saw as symptomatic of corruption and discrimination against them as poor people. We did not find the same level of acrimony in connection with access to medicines in the NGO clinics, but medicine was, nonetheless, a frequent concern. One 25-yearold woman with primary level education believed that the medications she received from the NGO clinic were ineffective because her symptoms had not resolved. She assumed she was being taken advantage of because she was poor: “There are [accredited] doctors in the [NGO] clinic but they do not give us the good medicine; they give to some, otherwise they would get caught, but only to those who are acquainted with them. But we can never say anything.” Because women have become used to leaving government facilities emptyhanded, it may not occur to them to ask that fees for medication be waived at NGO clinics.
Obligations among people In contrast to the oft-stated view among the study respondents that the poor typically face discrimination in health facilities, there was also evidence of a general expectation that one would not (or should not) be exploited or badly treated when there was a personal relationship involved. Cultural norms dictate that people should help their own when they can. As a result, in a context of widespread poverty, charging for services and commodities that used to be free or less expensive may be interpreted as exploitative. This line of thinking may explain why the local women who ran contraceptive supply depots in the NGO areas initially found it difficult to collect relatively nominal charges from their clients, as well as why some clients were not just
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disappointed but even bitter when they were not given services on credit. ‘Depot holders’ are volunteers who receive a small stipend from the NGO, supplemented with commissions from the sale of oral contraceptives, condoms, oral rehydration solution and a few other basic medicines. Depot holders in two rural sites complained that they faced difficulties in doing their work because women resented being charged for these commodities and thought it was inappropriate for a local person to earn money in this way. One of them quit her job, explaining, “Women thought that I got the pills [free] from somewhere and then sold them to them. People used to say that I made a living by selling pills.” In two places, staff conducting satellite clinics who had given services on credit asked the local depot holder to collect the money from the clients. They did this because the depot holder knew the women and lived near them, without understanding that it might be more awkward and difficult for her than for them to collect the money. In both urban and rural sites, it was obvious that clients were more willing to pay when they clearly understood that the clinics and supply depots were being run by NGOs, and that the charges were official, not informal. In one site a manager of the NGO compelled a group of local elected officials to assist in explaining the situation to the community and reassuring the NGO staff that if anyone had questions, they would provide verification that the charges were authorized.
Inseparability of cost and quality People interviewed often spoke about the provision of free commodities and services as if it were an aspect of service quality. The very poor in particular often said they preferred the services of village ‘doctors’ (who often lack accreditation) because these doctors know them, understand their situations and show compassion by providing free care or accepting whatever the patient is able to pay without asking humiliating questions. One urban woman explained: “If I am very ill, I go to a local doctor. He charges ten taka, and if I don’t pay it he doesn’t say anything. He understands how poor we are . . . . Or if I give him what I can and tell him that I’ll pay the rest later, he doesn’t object. He is sympathetic because of my distressed situation.” Another woman said of an NGO clinic, “Although I was empty-handed, they did not turn me away.” Others criticized the NGO clinics for their insistence on collecting payment of what were seen as trivial amounts of money for the NGO but substantial for the very poor. A pregnant woman with four children, whose husband was a vegetable farmer, complained that since the prices were the same for rich and poor, the poor had no “special place” at the clinic. She felt that the charges were generally reasonable but that, on principle, the poor should always be charged less. She seemed particularly critical of the practice of requiring repayment when a client was one or two taka short. Even shopkeepers waive one or two taka without much thought, she argued, “[Here] they take the four taka (leaving one taka outstanding) and tell the patient to pay it later or they will be responsible to Allah.”
One 35-year-old woman went to the NGO clinic, where she was unable to pay the consultation fee or the fee for the medication prescribed for her contraceptive side effects. Later she went to a government clinic and got the medication for free. Asked about her experiences at the two facilities, she commented: “The apas [at the government clinic] spoke to me angrily, but medicines are available there at no cost . . . . It is really good for me if I get free treatment and medicine. Even if I am scolded . . . the [government] hospital is better in every aspect – the behaviour of the doctors is rough, but so what? . . . The behaviour of the apas of the [NGO] is good, but what is the benefit of good behaviour if I do not get anything without money?”
Conclusions The NGOs have been charged with the very difficult task of expanding access to essential health and family planning services and at the same time maximizing cost recovery. They have been experimenting with a variety of strategies for accomplishing this double mandate, some more successful than others. The findings from this study illustrate some of the problems they are faced with, and some of their successes as well as ongoing challenges. In recent years, the interaction of gender inequality and poverty has resulted in greater mobility for women but constrained resources for women’s health – a difficult environment in which to implement health sector reforms that emphasize cost recovery for services directed primarily towards women. The central feature of the new NGO strategies is a strong emphasis on service quality, with particular attention to the interpersonal aspect of quality. Our study found some evidence of a new ‘consumer awareness’ among both clients and service providers. Many people showed an increased awareness that they had a variety of health care alternatives and chose to use the NGO services because they felt they got good value for their money, taking into account travel costs as well as fees at the clinics. It is also encouraging that prices established when the changes were instituted did not present a problem for the majority of clients. This finding is confirmed by a study undertaken in late 1999 in areas served by 10 of the urban NGO clinics, which found that some clients were willing to pay more than the prices then in effect (14–18% for various services). Sixty to seventy per cent said the prices were appropriate, and about 17–20% thought prices for various services were too high (Khan et al. 2000). Research undertaken in public sector facilities suggests a more complicated picture, noting that the prevalence of unofficial fees influences client attitudes about paying as well as their behaviour. The authors of one study suggest that prices charged in NGO and private facilities function as an ‘upper price boundary’ for unofficial charges in public facilities (Killingsworth et al. 1999). Thus, some people may be ‘willing to pay’ certain prices because they feel they have no alternative, not because they see them as fair or affordable. A study in conjunction with a pilot project in which user fees
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Paying for reproductive health services were introduced in public sector facilities found that about a third of clients had to borrow at least some portion of the fee paid (Saha and Bartlema 1998: 7). We would conclude from the body of findings on user fees in Bangladesh, including the results of the present study, that the NGO consortium must consider a wide range of factors in trying simultaneously to maximize access, quality and cost recovery. Finding an appropriate balance among these objectives requires more than devising an optimal pricing structure. Ability and willingness to pay are influenced by a complex of factors, including gender, class and ideas about entitlements, the role of government, the status of NGOs and obligations among people. Cost recovery might be strengthened and subsidies more effectively targeted if attitudes about charging and paying for women’s health services could be modified. However, this may be difficult to achieve without changing policies that influence these attitudes. Some policies have already changed in official documents. For example, the government’s 1997 Health and Population Sector Strategy focuses on meeting needs rather than motivating people to accept contraceptive methods. Compensation payments are not mentioned. There is an increasing cross-sectoral emphasis on interventions to reduce genderbased discrimination, such as female education and the use of mass media to promote positive gender role models. Over time, these measures may reduce the constraints to cost recovery that are rooted in gender inequality. There is increasing recognition both in the government health programme and among the NGOs in this study that increased outreach to men is needed, but there remains a clear need to implement male involvement strategies that go beyond the traditional exhortation to limit family size. The NGOs have come a long way in providing services that clients describe as fair and equitable to all. But the evident appreciation expressed by many clients, who felt they were treated with kindness and respect in the NGO clinics, is countered by the widespread feeling that poor people face discrimination in health facilities and quality services are out of their reach because they cannot pay for them. In particular, the very poor associate quality with compassion, which is considered a personal attribute rather than an institutional standard of care. Compassion encompasses providing free services or credit without humiliating the client. For the most disadvantaged, the ‘bottom line’ is that service quality is meaningless without access, and the manner in which access is granted reflects the stance of health providers, the government and society towards the poor. Providing needed services to those who cannot pay for them is viewed as morally right and an acknowledgement of a human bond between the poor and the powerful. In other words, questions of how much, whom and how to charge for health commodities and services are laden with symbolic and political meaning as well as cost–benefit implications. Policymakers and service providers need to take these social and cultural meanings into account to ensure that policies and programmes achieve not only financial sustainability but also social sustainability, by gaining community acceptance and respect.
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Endnotes 1 Among clients of 55 different Thana Health Complexes, between 25 and 50% reported paying unofficial charges for services. About half thought that these were official charges (Government of Bangladesh 1999). 2 The community level family planning worker (who no longer exists under the new system) typically established personal relationships with her clients and was often seen as an intermediary, in the sense that she knew the system and the clinic staff, and could use her influence to help the client get what she needed without unnecessary payments. 3 A similar phenomenon was documented in Thailand: individuals with insufficient financial capital relied on social capital to get access to health care (Reeler 1996).
References Alderman H, Lavy V. 1996. Household response to public health services: cost and quality tradeoffs. World Bank Research Observer 11: 3–22. Bates L, Islam MK, Schuler SR, Alauddin M. 2000. From the home to the clinic: the next chapter in Bangladesh’s family planning success story-rural sites. Report prepared for USAID/Dhaka and the Frontiers Project. Gallen M, Lettenmaier. 1987. Counseling makes a difference. Population Reports, Series J., No. 35. Government of the People’s Republic of Bangladesh. 1999. Thana Functional Improvement Pilot Project. Dhaka: Ministry of Health and Family Welfare, Government of the People’s Republic of Bangladesh. Haddad S, Fournier P. 1995. Quality, cost, and utilization of health services in developing countries: a longitudinal study in Zaire. Social Science and Medicine 40: 743–53. Hardee K, Smith J. 2000. Implementing reproductive health services in an era of health sector reform. Washington, DC: Policy Project. Hassan M. 1999. Bangladesh: Local Governance Survey. Dhaka: One World Action. Hotchkiss DR, Rous JJ, Karmacharya K, Sangraula P. 1998. Household health expenditures in Nepal: implications for health care financing reform. Health Policy and Planning 13: 371–83. Khan MM, Quayyum Z, Ahmed S, Sohel N, Dhar BC. 2000. Health seeking behavior, willingness and ability to pay for selected health services in Urban Health Partnership (UFHP) areas of Bangladesh. Dhaka: UFHP and USAID. Killingsworth JR, Hossain N, Hedrick-Wong Y, Thomas SD, Rahman A, Begum T. 1999. Unofficial fees in Bangladesh: price, equity and institutional issues. Health Policy and Planning 14: 152–63. Levin A, Caldwell B, e-Khuda B. 1999. Effect of price and access on contraceptive use. Social Science and Medicine 49: 1–15. Litvack JI, Bodart C. 1993. User fees plus quality equals improved access to health care: results of a field experiment in Cameroon. Social Science and Medicine 37: 369–83. Murphy E. 2000. Client-provider interactions in family planning services: guidance from research and program experience. MAQ Papers, vol. 1, no. 2. Boston, MA: Management Sciences for Health. Quayyum Z, Thwin AA, HBaqui A, Mazumder MA, Begum A, Sobhani J. 1997a. Mechanism for MCH-FP services of NGOs in urban Bangladesh: a preliminary assessment. Dhaka: International Centre for Diarrhoeal Disease Research, pp. 44. Quayyum, Z., Thwin AA, Baqui H, Mazumder MA. 1997b. Willingness to pay for MCH-FP services for NGOs in urban Bangladesh. Presented at the 125th Annual Meeting of the American Public Health Association (APHA), Indianapolis, Indiana. Raymundo C, Cruz G. 1993. Family planning client-worker interaction as an ingredient of the quality of care. Philippine Population Journal 9: 1–4. Reeler AV. 1996. Money and friendship: modes of empowerment in Thai health care. Amsterdam: Het Spinhuis.
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Acknowledgements We are grateful to the Pathfinder International/Dhaka Rural Service Delivery Partnership and, in particular, to Dr Md. Alauddin, as well as to Dr Ahmed al-Kabir and colleagues at the JSI Research and Training Institute’s Urban Family Health Partnership for their collaboration in this research. The research was supported by USAID through the Futures Group International POLICY Project Global Research Awards Program and the Population Council Frontiers Program, The William and Flora Hewlett Foundation, The Summit Foundation, and The Moriah Fund. The data were collected by: Shefali Akter, Shireen Akhter, Shamsul Huda Badal, Khurshida Begum, Rabeya Begum, Mahbuba Hoque, Rasheda Khan and Tofazzal Hossain Monju, with support from Nabeel Ashraf Ali. The authors thank Catherine Spaur, Sarah Martin and Diana Santillan for their contributions to the data analysis, and Karen Hardee for her comments on an earlier draft. The interpretations and conclusions contained herein do not necessarily reflect those of the funding agencies.
Biographies Sidney Ruth Schuler, Ph.D., a social anthropologist, is the founder and director of the Empowerment of Women Research Program, JSI Research and Training Institute, Arlington, VA, USA. She has over 20 years of international experience in research related to gender, women’s empowerment, health and development. She has undertaken several major research studies, in the course of which she provided training to teams of local colleagues in Bangladesh, Nepal, India and Bolivia. She has also worked as a consultant and served on inter-agency working groups concerned with the development of indicators for assessing gender equity and women’s empowerment issues. Lisa M Bates is a doctoral student in Social Epidemiology at the Harvard School of Public Health, Boston, MA, USA. She is concentrating on qualitative and quantitative research methods, gender studies and reproductive health. Lisa earned her Master of Science degree from HSPH in 1997 in Population and International Health. She has conducted research on international health and development issues for the Overseas Development Council, The Population Council, and The Harvard Center for Population and Development Studies. A consultant with the Empowerment of Women Program since 1997, Lisa served as the co-investigator on the program’s research in Bangladesh from 1998–2000. Md Khairul Islam, M.Phil, MBBS, is a public health physician and the director of Program Development Support at PLAN International, Bangladesh. He is also a consultant for numerous nongovernmental and governmental projects. Dr Khairul authored and co-authored several articles on a variety of public health issues. He was the co-Investigator in the Empowerment of Women Research Program’s multi-year qualitative study ‘From home to clinic: the next chapter in Bangladesh’s family planning success story’. Dr Khairul received his M.Phil in Preventive and Social Medicine from the National Institute of Preventive and Social Medicine (NIPSOM) at the University of Dhaka in Bangladesh. Correspondence: Sidney Ruth Schuler, JSI Research and Training Institute, Arlington, VA 22209, USA. Email:
[email protected]
