The authors examine accessibility and the sustainability of quality health care in a rural setting under two alternative cost recovery methods, a fee-for-service method and a type of social financing (risk-sharing) strategy based on an annual tax+fee-for-service. Both methods were accompanied by similar interventions aimed at improving the quality of primary health services. Based on pilot tests of cost recovery in the non-hospital sector in Niger, the article presents results from baseline and final survey data, as well as from facility utilization, cost, and revenue data collected in two test districts and a control district. Cost recovery accompanied by quality improvements increases equity and access to health care and the type of cost recovery method used can make a difference. In Niger, higher access for women, children, and the poor resulted from the tax+fee method, than from the pure fee-for-service method. Moreover, revenue generation per capita under the tax+fee method was two times higher than under the fee-for-service method, suggesting that the prospects of sustainability were better under the social financing strategy. However, sustainability under cost recovery and improved quality depends as much on policy measures aimed at cost containment, particularly for drugs, as on specific cost recovery methods.
PIP: In Niger the Ministry of Public Health in 1989 carried out a pilot test on a pure fee-for-service financing mechanism and a local social financing mechanism, a tax + fee-for-service, for a national cost recovery health policy. Three health districts were selected: the District of Say, the District of Boboye, and the District of Illela. The fee-per-episode of illness method was instituted in the District of Say where fees were set at 200 FCFA ($0.66) per user 5 years and older and 100 FCFA ($0.33) for children under 5. The second method was implemented in the District of Boboye in the form of a local, annual tax of 200 FCFA ($0.66) to be paid by the district taxpayers and a small fee-per-episode to be paid by users of public health facilities. A baseline survey collected information on the curative health behavior of 2710 individuals who reported illness during the last 2 weeks preceding the survey. Information was also collected on preventive care behavior from 1770 childbearing women for the baseline survey and 1615 childbearing women for the final survey. Information on monthly activities and utilization of the 23 health facilities was collected for the year preceding the launching of fee collection, the base year, May 1992-April 1993, and the year following the launching of charges at public facilities, the test year, May 1993-April 1994. In the District of Say the number of visits declined slightly, but the total quantity of care increased significantly. In contrast, the number of initial visits increased by nearly 40% in the District of Boboye, and significant improvement was observed in the utilization of public health facilities among children and women. Overall, people spent less on health care across the 3 districts during the test period than they did before. Furthermore, drug consumption at public health facilities in the 2 test districts was well below current needs.