title: Health worker perspectives on user fee removal in Zambia.
abstract: BACKGROUND
  User fees for primary care services were removed in rural districts in Zambia in 2006. Experience from other countries has suggested that health workers play a key role in determining the success of a fee removal policy, but also find the implementation of such a policy challenging. The policy was introduced against a backdrop of a major shortage in qualified health staff.
  
  
  METHODS
  As part of a larger study on the experience and effect of user fee removal in Zambia, a number of case studies at the facility level were conducted. As part of these, quantitative and qualitative data were collected to evaluate health workers' satisfaction and experiences in charging and non-charging facilities.
  
  
  RESULTS
  Our findings show that health-care workers have mixed feelings about the policy change and its consequences. We found some evidence that personnel motivation was higher in non-charging facilities compared to facilities still charging. Yet it is unclear whether this effect was due to differences in the user fee policy or to the fact that a lot of staff interviewed in non-charging facilities were working in mission facilities, where we found a significantly higher motivation. Health workers expressed satisfaction with an apparent increase in the number of patients visiting the facilities and the removal of a deterring factor for many needy patients, but also complained about an increased workload. Furthermore, working conditions were said to have worsened, which staff felt was linked to the absence of additional resources to deal with the increased demand or replace the loss of revenue generated by fees.
  
  
  CONCLUSIONS
  These findings highlight the need to pay attention to supply-side measures when removing demand-side barriers such as user fees and in particular to be concerned about the burden that increased demand can place on already over-stretched health workers.
authors.affiliation: London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. barbara.carasso@lshtm.ac.uk.
authors.forename: Barbara S
authors.initials: BS
authors.lastname: Carasso
authors.forename: Mylene
authors.initials: M
authors.lastname: Lagarde
authors.forename: Caesar
authors.initials: C
authors.lastname: Cheelo
authors.forename: Collins
authors.initials: C
authors.lastname: Chansa
authors.forename: Natasha
authors.initials: N
authors.lastname: Palmer