The effect of user fees on the utilization of family planning services. A clinical study

Abstract

A new fee structure was introduced to the Advanced Training and Research in Fertility Management Unit in 1992. The study looked at the effect of the new fees on attendance and the choice of contraceptive methods through an examination of clinical records and a questionnaire survey. There was a decline in attendance of roughly 28 per cent between 1992 and 1993. The decline affected mainly new clients and those who accepted injectables. A reduction in the price of injectables is suggested since the fee for this short-term method is more in line with those charged for long-term and permanent methods.

PIP: In order to foster the self-sustainability of its family planning (FP) program, Jamaica has introduced user fees for previously free FP services. In 1992, donations were solicited for injectables and sterilization. By January 1993, a fee of J $200 was set for sterilization, and fees for other services were introduced. A study was undertaken to 1) examine the effect of the new fee structure on clinic attendance; 2) determine the extent to which the fees might have encouraged a shift to other methods; and 3) establish a range of affordable prices for current users. Data were collected from clinic attendance records for January-April of 1990-1992 and compared to the same period in 1993. A 20% sample of clients (n = 1002) attending in January of each year was followed for 4 months to allow comparisons of method changes. Finally a questionnaire was administered to a 25% sample of daily users (n = 200) over 4 weeks in February 1993 to determine affordable fees. It was found that there was a 28% decline in attendance in 1993 over 1992 despite a temporary halt in sterilizations in early 1992. The number of new clients in 1993 increased but failed to reach the 1990 level. The number of old clients attending in 1993 was the lowest for the 4 years. In early 1992, there was a shortage of injectable contraceptives. Despite this, injectables were used 7% more in 1992 than in 1993 when a fee of J $100 was established. Almost a third of the sample of new clients accepted sterilization in 1993, and all of the women kept their appointments unlike previous experience (perhaps out of fear of a higher fee in the future). 1993 also saw the highest percentage of drop-outs of any year studied. Current prices charged by the clinic for oral contraceptives, injectables, and sterilization were acceptable to 85, 23, and 13% of the women, respectively. The substantial drop in clientele over a single year affected mainly clients using injectables. A reduction in the price of this method seems justified not only by the loss of clients but also because the fee for this method is higher than that for longterm or permanent methods. Costs could also be subsidized by other strategies, such as allowing higher income couples to pay a fee to secure an appointment instead of having to wait. Future price increases should be gradual, since increases of 10% a few times a year are less likely to result in patient loss.