The following sections present the results of the analysis of this intervention, starting with the perception of its relevance and feasibility, then the implementation process, and finally the intervention's unintended outcomes.
Perceptions about the judiciousness of user fees abolition
Opinions on the judiciousness of the fees abolition varied widely depending on the actors and can be summarized in three categories.
i) For the abolition
The group made up mostly of the populations and the target groups (beneficiaries) unanimously considered abolition to be justified. The abolition of fees produced peace of mind and encouraged people to attend health centres. In fact, some told us it was common for people to pawn their fields to obtain the means to pay for health care. Most persons we questioned did not seem to perceive any injustice in some people paying and others not. Children and women were seen as being vulnerable. Easing the financial burden benefited the entire household, which everyone considered to be positive.
ii) Yes, but..
Health officials and local government decision-makers (legitimizers) were in favour of abolition because, in their view, it led to increased utilization of services. However, they worried that the State was relatively incapable of sustaining such a measure. They noted the difficulty of embedding the abolition of fees into the CR system, which itself had required a long time to organize and to get people used to paying. "The NGO's intervention is a wound that has already done damage," said one administrator. Thus we were told, in a phrase that was surprising coming from a Sahelian, that it was better "to teach people to fish than to give them fish." Their proposal therefore was that everyone should participate financially. Otherwise, they would prefer to see abolition introduced gradually, not suddenly.
iii) Against the abolition
Among health workers, opposition to free services was more widespread, although not total. They would have preferred to see drugs made available at lower prices and more accessible, rather than abolishing payment altogether. They asserted that abolition had provoked unwelcome behaviours among patients: lack of respect and of appreciation for services rendered, poor maintenance of health booklets, etc. They believed even a symbolic payment would be preferable to "disturbing a well established system that works well enough." The population's financial participation was still seen as a way of instilling a sense of ownership and respect for services. However, health workers were not unanimous in their opinion, since the statement "if patients don't pay for services, they don't value them," did not receive a majority of votes – 33% agreeing completely and 20% not at all (Table ). Finally, other health care workers opposed free services because they said these had increased their workload.
Health staff perceptions (in %)
Perceptions about the sustainability of user fees abolition
In terms of sustainability, the general view that emerged was of abolition as a temporary phenomenon. The intervention was seen as an experiment or a project. One nurse said, "I have the impression that Niger has become a laboratory for testing all the systems, a guinea pig country." This view refers back to the experiment conducted in Niger that is often cited to justify CR policies [43
]. In the popular imagination (after decades of experience with development projects), a project does not last; it is short-lived. One respondent from high up in the administration considered this project to be "assistance". One health worker at a health post, where free services are not yet offered as they are in the CSI, believed the State could not do it. According to him, this abolition was tied to a project. "You've seen it, it's foreigners who have come and given these free services," he told villagers, in justifying the fact that he continued to charge for services. There was also widespread concern about the State's capacity to carry forward this abolition introduced by an NGO. "Once HELP is over, things become risky," one nurse said. Nearly 30% of health workers thought the State could not keep it up. More than 40% believed the State would not be able to reimburse free services. Likewise, more than 50% believed the State will not be able to provide sufficient quantities of drugs once the NGO and its supply system come to an end (Table ). Between scepticism and lack of confidence, the actors seemed to consider that a State-managed abolition of fees is destined for failure. The State's move to extend free services to the entire country was perceived as political. Among those we encountered, the political was often equated with deceitfulness. Others went so far as to propose a substitution: "We might just as well have HELP do it, because the State can't," said one village treasurer.
Strengths of the implementation process
i) A top-down information and community awareness phase
Local authorities largely participated in the dissemination of information on the abolition. The NGO relied on both traditional and administrative channels of information to explain clearly their objectives and the target groups for their activities. The usual procedures were followed with utmost respect to involve local leaders and decision-makers in the information phase. Admittedly, they were involved very little, or even not at all, in the decisions and the choice of intervention modalities, which some people, particularly the nurses, deplored. Nevertheless, their involvement in the top-down strategy definitely helped in disseminating information. Also, the NGO was able to organize space where they could provide local partners with regular updates on their activities; for some officials, this brought real added value to this NGO, as compared to others about which, according to one prefect, very little was known.
ii) Incentive measures
The NGO perfectly anticipated the reluctance of those involved in the implementation, by organizing incentive measures substantial enough to limit abuses – although not all of them, as we shall see later. The financial data show that the operating grants to the CSIs were sufficient to avoid any de-capitalization that would have endangered the COGES' sustainability. According to official data, the rate of cost recovery remained above 100%. Everyone involved appreciated that the salaries of the community fees collectors and the COGES treasurers remained more or less at the same levels as before. In some CSIs in Mayahi and all CSIs in Tera, this grant even allowed these persons to earn more.
iii) Drug supplies
Overall, everyone agreed the supply of drugs was well organized. This was all the more appreciated because the State system does not work well. Admittedly, there were some shortages and occasional problems in adjusting the supply with unrealistic demands by nurses at the beginning of the intervention. The cost recovery drugs were often stashed in cupboards while those from HELP were kept at hand for the many consultations. In addition, new drugs appeared in the prescriptions of health workers who understood them: ocytocics, magnesium sulfate and, of course, sulfadoxine-pyrimethamine, which replaced chloroquine for pregnant women, as well as the other antimalarials that were replaced. The NGO trained all health workers in the rational use of essential generic drugs and in new treatment protocols (such as stopping the use of chloroquine).
iv) Medical evacuation system
Everyone acknowledged HELP's very significant role in medical evacuation and in rapid and free response to emergencies. Evacuation was being done quickly, whereas before, under the cost recovery system, patients had to return home to find the money required.
Weaknesses of the implementation process
Beyond these strengths, certain limitations were also raised. We focus here on the most important, in terms of lessons applicable to other interventions.
i) The information and community awareness phase
Because the process relied primarily on local authorities and leaders, others such as community officials, COGESs, and street level workers were sometimes left out. Thus, there were breakdowns in transmitting information to villagers. The NGO left this responsibility to village chiefs and sometimes to CSI nurse managers, who did not always carry it out well. One woman said, "When they introduced free services, they didn't call us together to tell us about it; I learned about it from women who came for prenatal visits." Some people only found out at the CSI, when it came time to pay. Also, the quality of information was sometimes inadequate, and the announcement of the free services was sometimes incomplete or poorly explained to the public. For instance, while some women we encountered knew what the target groups were, they did not always know what services were covered by the abolition.
ii) Incentive measures
Despite the positive aspects of the incentive measures described earlier, two problems nevertheless arose. The first concerned the fact that some CSIs had guards who were paid from cost recoveries. Because these salaries were not covered by the HELP grant, some CSIs continued to charge each patient 25–50 F CFA (0.5–0.10 US$) to pay for the guard. The second problem had to do with the per diem
spiral, a perverse effect that is well known in development projects [42
]. To ensure the CSI managers would accept the intervention, and on the pretext that, according to them, this would increase their workload, the NGO agreed to give them an "incentive" – a monthly bonus of 20000 F CFA (45 US$). However, the State will not be able to assume this cost and the workload excuse does not appear to be justified at the time of this evaluation. The CSI managers were asked to share this bonus with the other workers, but this was not done everywhere.
iii) Lack of COGES involvement in the system
The COGESs were not always kept informed and rarely participated in the implementation. Thus, the CSI managers are the masters of the system. A glaring example of this low level of involvement was the spontaneous reaction of the members of one district team to our desire to assemble the COGES presidents for a group discussion on fees abolition: "But the presidents don't know anything!" While it may be that most district COGESs do not function well, they were certainly not strengthened by the intervention and, in some cases, may even have been destabilized.
iv) Introduction of parallel operating systems
One of the major weaknesses of the project was the creation of two parallel operating systems, rather than integrating this intervention into the existing system using a systematic approach to support the district health team. Unfortunately, as one chief physician told us, "they have nothing in common." Fees abolition became a vertical program, like vaccination. Nurses had to manage different groups of registered patients, some in the CR system, some in the HELP system. We could even say there were multiple functions, having observed that CSIs already had the experience of free services provided by other NGOs (Islamic Relief, World Vision) or in other programs (tuberculosis, leprosy, etc.). Concretely, as one nurse said, in the CSIs there was "a BI table and a free services table," where drugs were provided, but "it's very difficult for one worker to be applying two different management systems." For many people, this clear distinction was justified for accounting transparency and for the NGO's visibility. Also, as one nurse said, "with HELP, the BI was completely turned upside down." A recurrent complaint was the cumbersome bureaucratic necessity of filling out administrative documents in duplicate so the funding agency could have the specific data it required. Moreover, district teams were not really involved in the NGO's activities. They did not receive copies of the drug stocks received, participate in their distribution, or carry out coordinated supervision.
v) Lack of action to reinforce the supply side
The abolition of fees undoubtedly acted upon demand by reducing the financial burden. Supplying drugs to the CSIs allowed the supply to respond, but only in part, to the demand. Also, the NGO had not done enough so that the supply could respond better to increases in demand. Sending in an intern to supplement human resources was a late decision, but not a sustainable solution. There was not enough institutional support in terms of equipping and reinforcing the health system, despite the supplies of basic operating materials.
vi) Lack of follow-up in the medical evacuation system
Setting up the medical evacuation system was a major accomplishment of this project. However, there was not adequate follow-up to ensure that the women for whom the NGO reimbursed services at the referral centres actually received these services at no charge. Some women complained, "Before, we had to pay 20000 F CFA for gas; now it's free, but when we get to the Regional Hospital, we have to pay." Thus, there was the risk that women's hopes, raised by the organization of medical evacuation services and free caesareans, would collapse because of poor follow-up and management inconsistency between HELP on one side and the State on the other.
vii) Coordination of the levels of free service in the health pyramid
Similarly to the problems in the evacuation system, the modalities for fees abolition had not really been coordinated between the various levels of the health pyramid. Apparently the funding agency requested that the NGO not intervene in the hospitals and health posts. Thus, services are free in CSIs for women and for children under five, but if they are evacuated or go on their own to a health post at a higher level in the hierarchy, or if they come from a lower level in the pyramid, they have to pay.
Actor's perceptions of outcomes
Table presents the results of the questionnaire administered to the health personnel. With respect to patients, the personnel clearly saw a positive impact of fees abolition on service utilization; 94% agreed completely with the proposition of an increase stimulated by the abolition of fees. All (100%) believed this had resulted in more people being treated than before. Moreover, they said the abolition had helped the more vulnerable. They also believed the abolition had some negative impacts on patients. The same proportion (two-thirds) thought that: i) abolition had increased the number of patients who try to abuse the system; ii) people confused abolition with free distribution of drugs; and iii) more people now tried to obtain drugs when they were not sick. For example, one nurse said, "Some women arrive with the name of the drug they want." Regarding impacts on their professional practice, more than 80% of the workers stated that they felt personally affected by the implementation of the abolition. 64% stated that this had positive impacts on how they treated patients (improved quality). However, a majority of staff complained of the added administrative and clinical workload. But based on our observations in the field, we calculated that a nurse spent an average of eight minutes with each patient. This corresponded to about 4.1 hours of curative work per day in Mahayi and 2.6 hours in Tera. In Mayahi, the maximum number of consultations per day after fees abolition was 31, in the fourth quarter of 2006, and 20 in Tera, in the third quarter of 2006. Also, a majority (55%) did not think the abolition prevented them from treating everyone who came. In summary, they told us there was more work but no reduction in quality, nor selection of patients treated. No consensus emerged on perceptions of the extent of personal impacts, on operations, on professional burn-out, or on pressures experienced. Table (based on this questionnaire and qualitative data) summarizes workers' perceptions of the intervention's outcomes, as well as what we heard from women and members of the management committees.
Summary of the actors' perceptions of the impacts of fees abolition
Workers' negative perceptions of women's supposedly improper behaviours have consequences, women said, on how they are received by the nurses. One patient explained,
"Even though it's free, before it started, and now, it's not the same. Before, when you came, they gave you a tube of ointment, but now, you bring your child in the morning and again in the evening for them to put the medicine in his eyes."
Another woman made it clear that abolition did not always mean things were free, since, "Before, we gave 800 francs and today we give 200 francs, it's as if they have lowered the price. So we can say 'Alhamdu lilahi' (Thanks be to God)." Members of the COGES also were not pleased that drugs related to the abolition were managed by the nurses and no longer by the management committees created by the BI.
Some unintended/undesirable outcomes
Our aim in this section is to describe some unexpected outcomes provoked by the abolition of fees implemented during this NGO intervention – a type of analysis rarely undertaken, according to certain experts in evaluation [44
]. The social actors adapted to this financial innovation in ways designed to minimize disadvantages to themselves.
i) From the population's perspective: medicines associated with the distribution of food aid
Two years before this health intervention, the NGO had begun its action in Niger by distributing food supplies during the food crisis in 2005. Thus, the abolition of user fees, and the abundance of new consultants and drugs to cope with it, was sometimes interpreted by the population as a distribution of medicine. As with food aid, where the organizers are very aware of pilferage, "there was lots of wastage" in the first weeks of the intervention, one nurse told us. Thus, not knowing whether this windfall would continue, or to make sure they would have medicines for when their children actually became sick, some patients apparently came to the centres to build up a reserve of medications; "there's a big rush on, because it won't last," said a nurse. Thus, according to the nurses, there was a phenomenon of stockpiling.
ii) From the perspective of the healthcare workers: strategies for recuperating the shortfall
Health care workers have always organized parallel systems to boost their incomes. These parallel practices were integrated into a system where people paid for everything. Thus, the act of abolishing some fees and informing the population of that fact made these strategies more complicated (but not impossible) to carry out. Nevertheless, the health care workers managed to adapt perfectly well to the new situation. All of them insisted that the abolition of fees greatly increased their workload "to the point of irritation" and reduced the time available for each patient – a claim that was not borne out by our observations. These statements are somewhat exaggerated; the most motivated workers managed to better organize the distribution of tasks and the roles of the health personnel. Actually, the strategy behind these statements is to pressure the NGO to recognize that they are "overwhelmed" and consequently to increase the bonuses they receive for working in the free system. Some nurses redirect the free drugs from the NGO into the fee-for-service system that continues for other categories of the population who are not beneficiaries of the project. Creating artificial stock shortages of goods supplied for free by the NGO is another way of getting around the NGO's rules. By forgetting to replenish the stocks of health booklets, nurses will create a shortage that will allow them to purchase the same booklets manufactured in neighbouring Nigeria, which they then resell to patients privately at a profit. Others are even more creative. On the pretext that the women do not take proper care of the health booklets, some nurses have "required that the booklets be plastified," said one manager, for the same price at which they used to be sold. Other nurses write their prescriptions on a piece of paper that they staple to the booklet, then charge 25 F(0.05 US$) for the staple. We were thus not surprised to see a nurse open, inadvertently, a drawer filled with coins in his office. The other solution is simply to charge for certain services that are free. One woman told us, "I paid 1,000 F (2 US$) for a delivery a few days ago." Another woman recounts that she paid for her first prenatal consultation; but the health workers had chided her for coming in, because they took advantage of the rural inhabitants' lack of information to charge them when they came into town for services, so they said to her, "Hey, city-dweller, why did you come today? Today is for the peasants, they pay cash, so you'll have to pay, too." Some CSIs continue to charge each patient 50 F or 25 F to pay, we were told, the salary of a guard. Thus, one woman reported having been charged several fees: "I didn't have to pay for the awo [antenatal care], but I had to pay for the booklet. So, I paid 100 francs for the booklet, 100 francs to have it plastified, and 25 francs for the guard." When we asked women who were waiting in line in front of a CSI why the services had become free, the response suggested to us that it was not always so: "It's because you are here today." We were also told that the abolition of fees "created problems of misunderstanding between the health workers and the population."
iii) The provider-patient relationship: lack of understanding
The abolition of user fees had several impacts on medical practice and particularly on the interaction between provider and patient. Many patients consider that the medicines supplied in the free system are, in effect, owed to them by the NGO and made available through the CSIs, and that health workers are only intermediaries whose role is to distribute them. This lack of understanding about the abolition of user fees has led users to develop strategies for hoarding medicines. Thus, the majority of nurses (63%) completely agreed with the statement that abolition required them to deal with patients who were not sick and wanted to abuse the free system. According to the nurses, patients have adapted their strategies for acquiring medicines. Some pretend to be sick, and others, who arrive with a healthy child, listen to the description of the symptoms of the mother ahead of them in line and say the same things that will help them get the medicines they want. Since many nurses do not systematically take vital signs (none that we observed did so) and provide care based only on reported symptoms, the likelihood that mothers will be given medicines is quite strong. Some people go from one CSI to another. The massive arrival of cough syrup was perceived by mothers as a great opportunity because they associate it with vitamins. Thus, as one nurse reported, "we were obligated to give the cough syrups to the mothers." Moreover, health workers say patients have become more demanding and insist on receiving the treatment of their choice. They arrive late at night, even for a mild cold. We did not observe any such behaviours during our observations in 12 CSIs and can only repeat here what was reported by the nurses.
However, patients are not happy, either, with how they are treated. Complaints about health workers are frequent. For example, they complain that workers ration the medicines. In addition, they find that the workers are scornful toward them, treating them as though they are pretending to be sick and only come to the CSI to get medicines.