title: Maintaining quality of health services after abolition of user fees: a Uganda case study.
abstract: BACKGROUND
  It has been argued that quality improvements that result from user charges reduce their negative impact on utilization especially of the poor. In Uganda, because there was no concrete evidence for improvements in quality of care following the introduction of user charges, the government abolished user fees in all public health units on 1st March 2001. This gave us the opportunity to prospectively study how different aspects of quality of care change, as a country changes its health financing options from user charges to free services, in a developing country setting. The outcome of the study may then provide insights into policy actions to maintain quality of care following removal of user fees.
  
  
  METHODS
  A population cohort and representative health facilities were studied longitudinally over 3 years after the abolition of user fees. Quantitative and qualitative methods were used to obtain data. Parameters evaluated in relation to quality of care included availability of drugs and supplies and; health worker variables.
  
  
  RESULTS
  Different quality variables assessed showed that interventions that were put in place were able to maintain, or improve the technical quality of services. There were significant increases in utilization of services, average drug quantities and stock out days improved, and communities reported health workers to be hardworking, good and dedicated to their work to mention but a few. Communities were more appreciative of the services, though expectations were lower. However, health workers felt they were not adequately motivated given the increased workload.
  
  
  CONCLUSIONS
  The levels of technical quality of care attained in a system with user fees can be maintained, or even improved without the fees through adoption of basic, sustainable system modifications that are within the reach of developing countries. However, a trade-off between residual perceptions of reduced service quality, and the welfare gains from removal of user fees should guide such a policy change.
authors.affiliation: Health systems unit, World Health Organization, Kampala, Uganda. nabyongaj@ug.afro.who.int
authors.forename: Juliet
authors.initials: J
authors.lastname: Nabyonga-Orem
authors.forename: Humphrey
authors.initials: H
authors.lastname: Karamagi
authors.forename: Lynn
authors.initials: L
authors.lastname: Atuyambe
authors.forename: Fred
authors.initials: F
authors.lastname: Bagenda
authors.forename: Sam A
authors.initials: SA
authors.lastname: Okuonzi
authors.forename: Oladapo
authors.initials: O
authors.lastname: Walker
mesh_terms: D002391:Catchment Area, Health; D005249:Fees and Charges; D005260:Female; D006268:Health Facilities / Q000145:classification / Q000592:standards*; D006801:Humans; D007407:Interviews as Topic; D008137:Longitudinal Studies; D019982:Organizational Case Studies; D010342:Patient Acceptance of Health Care / Q000523:psychology* / Q000706:statistics & numerical data; D004364:Pharmaceutical Preparations / Q000191:economics / Q000600:supply & distribution; D011203:Poverty; D011332:Privatization; D017064:Process Assessment, Health Care / Q000379:methods; D011635:Public Health Administration / Q000191:economics* / Q000331:legislation & jurisprudence; D036301:Qualitative Research; D011787:Quality of Health Care / Q000191:economics*; D014454:Uganda; D017664:Uncompensated Care
chemical_list: D004364:Pharmaceutical Preparations