Goal 6: quality

Additional revenues from user fees can be spent on different aspects of service delivery that improve the quality of care. More resources available at the decentralised levels of the government structure should also improve accountability, which in turn should improve quality. Unfortunately, the lack of data, as well as difficulties defining what constitutes quality, have made it difficult to monitor the quality impact.

Retention of collected funds at the local level where they were collected has, however, been shown to be important in many settings. Retained revenues can be spent on immediate quality improvements such as drug purchases, upkeep of buildings and equipment, and salary supplements for providers to enhance motivation. Without local retention of the revenues, the links between user fee collection, accountability and quality improvement are broken. See Cost-sharing in Kabarole District, Western Uganda.

Corruption, bureacracy, and poor planning can stop quality from improving

In many settings there have not been major observed improvements in quality. Reasons include corruption, bureaucracy, lack of planning for use of funds, insufficient funds, difficulty of obtaining the resources or services needed for major quality improvements, and inefficient spending. See User fees in government health units in Uganda. In a number of countries (Eritrea, Ethiopia, Namibia, Zimbabwe), revenues collected were sent back to the central treasury. In others, central government has withdrawn its funding because it assumed that the decentralised levels had become self-sufficient in covering recurrent expenditure.

It has been argued widely that when there are quality improvements, the negative effect of user charges on utilisation is often off-set, with some increases in utilisation found amongst even the poorest. Lessons from cost recovery in health shows that improved quality more than offset price effects of user fees, resulting in net increases in utilisation of health services in utilisation in health services in Cameroon, the Gambia, Niger, Sierra Leone, Sudan and Zaire. In Ghana the outpatient consultations held roughly constant in the years before and after introduction of user fees, with an improvement in drug supply (see Health for some? The effects of user fees in the Volta region of Ghana).