Household Coping Strategies In Response To The Introduction Of User Charges Of Social Services: A Case Study On Health In Nigeria

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1.1 Background
In the late eighties there was considerable pressure on governments in many parts of the world, particularly
those forced by deteriorating economic circumstances to undertake major economic restructuring, to introduce
user charges for services such as health and education which in some cases had traditionally been seen as ‘free’.
(Creese, 1991). Such charges, it was argued, would not only increase efficiency in line with standard neoclassical
economic theory (Akin, 1986), but could also promote equity by reducing the tendency for services
funded by taxation to be ‘captured’ by wealthier, often urban, populations (Griffin, 1992).
The widespread acceptance of health sector user charges was a reflection of the increasing difficulties most
governments were facing in sustaining adequate expenditure levels (Kanji, 1989). The combination of economic
crisis, increasing population and high disease incidence, including the AIDS pandemic, forced most sub-Saharan
African governments to seek new options for raising resources, with the 1987 World Bank policy paper on
health financing (World Bank, 1987) providing the main focus. Among a range of other policies, this advocated:
charging fees to the non-poor at public health facilities, decentralising as many health activities as possible, and
developing risk sharing mechanisms to protect the population from catastrophic health expenses
There is now a collection of research findings on the impact of cost-recovery schemes on health service
utilisation and revenue generation (Gilson, 1995). However, they provide radically divergent results. Heller
(1982) and Akin (l986) found that price increases had minimal effect on the decision to seek health care in
Malaysia and the Philippines. Meyer (l985) found similar results in Mali. On the other hand, Waddington and
Emjimayen (l990) demonstrate that utilisation of health care in Ghana was severely affected by a substantial
increase of health care prices in l985. Similarly, Mbugwa (l993) in a Kenyan study found that utilisation of all
government health facilities fell sharply after the announcement of user charges, while attendance at
dispensaries which continued to provide free services rose. This study also found that the poor were more
sensitive to price than the rich, as did research in Cote d’Ivoire and Peru (Gertler and Van der Gaag, 1990) and
in Swaziland (Yoder, 1989). However, Akin (1995) finds no differences in price responsiveness in a Nigerian
The great majority of studies have focused narrowly on the introduction of user fees and the short-run
implication for utilisation and revenue generation. Limited work has been undertaken on the effect of user
charges on general household expenditure patterns and coping strategies (Russell, 1996), and the few findings
available are contradictory. Studies in Ghana (Waddington, l990) and Tanzania (Abel-Smith, 1992) indicate a
considerable impact on household resources, while a general review of the Bamako Initiative in Africa (McPake,
1992) finds little evidence.
There is an urgent need to clarify these issues. Households in countries which have adopted health sector
cost-recovery policies are simultaneously having to deal with the impact of a range of other financial burdens
arising as a consequence of economic crisis. Even if utilisation of health services is maintained, it is essential to
know if this is being achieved by reductions in other aspects of well-being, for example by asset sale, or reduced
expenditure on food or education, or by individual sacrifices made by some members of the household, for
example by mothers on behalf of their children. If this is the case, there are liable to be serious implications for
the longer-run health and welfare of such households. The aim must be to develop policies which allow and
facilitate the adoption of appropriate, sustainable coping strategies at the household level.

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