User fes and ability to pay: A comparative study on quality of care in Siraha and Lahan hospitals, Nepal.

Thesis Report.

SUMMARY: User Fees at government health facilities are being promoted, increased or introduced internationally. It is suggested that user fee for those who can afford to pay is a useful policy instrument for promoting health policy objectives: greater efficiency, through their influence both on provider and user behavior; greater sustainability of health services of adequate quality through the generation and use of additional resources: and greater equity, by cross subsidization of more accessible and higher quality services for the poor (World Bank 1993). Siraha and Lahan hospitals are providing health services to the patients referred from 115 health facilities (HP, SHP, PHCC) in Siraha District. Despite the high prevalence of disease, the service utilization rates of these hospitals are considerably low; less than 3% of the population, visit these hospitals. Low utilization of hospital services, might be two fold one due to the financial inaccessibility and two, because of more accessible to the traditional healers or patients perceive the quality of services in hospital is not good. Patients pay a very nominal registration fee Rs. 5/- (USs 0.14) which constitutes only 3-4% to the total operating cost of the hospitals. According to the 1997/98 report, both hospitals collected Rs. 340,000 (US 4860) from user fee and stall rental. Due to the significant cost recovery in Siraha and Lahan hospitals, quality of health services could not be improved and utilization rate has been declining. There is still an enormous potential available to raise the funds if the affordable user fees ins introduced. It will improve the quality of services and access to the users who are not utilization the public health facilities. The overall objective of this descriptive study was to assess the users ability to pay fees for health services and their perceptions on the quality of services in Siratha and Lahan hospitals, Nepal. The study was based on the use of quantitative and qualitative methods, using structured interviews, semi-structured interviews and focus groups discussion. A Total of 100 adult male and female patients were selected and interviewed with the purposive selection technique; at the exit poll of Siraha and Lahan hospitals. All exit interviews of the patients were conducted when the patient had gone through the registration, consultation, diagnostic measurement (laboratory and x-ray) and receipt of medicines from the hospital's pharmacy. Four focus groups discussion with 10-14 participants, were conducted in two municipalities. The selection of focus group interviews was on the basis of higher, lower, utilization of hospital service, depressed community "Tatma" and vulnerable (women) group in ward " Chenghai" Siraha. According to overall findings of the study, the quality of services in Siraha and Lahan hospitals was found low and patients were not satisfied with the services provided in the hospitals. Quality of services was perceived poor on the basis on non-availablity of medicine, laboratory test and long waiting time to see the health provider. Utilization of services was found higher among Hindus and low among Muslim ethnic groups. Private practice was found more common with the public providers who were charging fee twenty times higher than public hospital. Users were able an committed to pay higher fees in the public hospitals on the condition o availability of medicine, short waiting time and good consultation from the health provider. Ability to pay for services was found higher among Hindus and especially with rural community. Average expenses made on the treatment of last sickness episode was ranging from NRs. 1000-15000 depending on the severity of illness and importance of the number in the family. Priority for treatment was given to married woman, son and earning member in the family because their illness may effect the household activities and income. It is recommended that quality of services in the hospitals must be improved by ensuring the availability of medicine, equipments and technical manpower. Establishment of paying clinics (afternoon) and fair price drug shops in these hospital are recommended as patients and providers were agreed to use the health facility. 1. On the basis of finding of this exploratory study, it is recommended that a study on a representative sample to access the perception of non users o hospital on the quality of services and their willingness & ability to pay should be carried out. 2. It is recommended by the researcher to initiate a study to determine the gender related factors associated with the willingness and ability to pay in Siraha district.

Eng.