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Table 3 Pressures mentioned in the literature by country, health system functions, and authors (1988 to 2009)

From: A literature review of the disruptive effects of user fee exemption policies on health systems

Health system functions Pressures mentioned in the literature
Ghana
Service delivery · Increase in utilization [21, 31, 32, 35]
Health workforce · Increase in workload, loss of income [31]
  · Insufficient medical personnel; increase in workload [32]
Health information · No information
Medical products, vaccines and technologies · No information on the number of acts and the amount of reimbursements [31]
Financing · Funding unpredictable, insufficient and discontinuous; problems with reimbursement in cases of referrals [31]
  · Funding unpredictable, insufficient and discontinuous; informal payments; health centres going into deeper debt [35]
Leadership and governance · Lack of information and complexity of funding procedures; poor supervision; problems in assigning responsibilities [31]
  · Lack of information and communication (funding); competition with other interventions; poor supervision; ‘no blame’ game [35]
Kenya
Service delivery · Increase in demand for service [36, 37]
Health workforce · Increase in workload [33]
Health information · No information
Medical products · Problems of availability and insufficiency of drugs and kits [33]
Financing · Informal payments [22]
  · Informal payments; loss of income for health centres [33]
  · Insufficient funding; informal payments [36]
Leadership · Poor understanding of the policy; problems in assigning responsibilities [33]
Madagascar
Service delivery · Increase in utilization [19]
Health workforce · No information
Health information · No information
Medical products · Problems of availability of drugs [19]
Financing · No information
Leadership · No information
South Africa
Service delivery · Increase in utilization [29, 3840]
Health workforce · Increase in workload; lack of time for consultations; feeling of being exploited; frustration, etc. [29]
  · Increase in patient/provider ratio [38]
Health information · No information
Medical products · Problems of availability of drugs [29]
Financing · No information
Leadership · Feeling of a lack of recognition among workers; poor planning and communication [29]
Senegal
Service delivery · Increase in utilization [23]
Health workforce · Increase in workload [23]
Health information · No information
Medical products · Delays and under-distribution of consumables [23]
Financing · Informal payments; delays in reimbursements; loss of revenue for the health centres [23]
Leadership · Poor understanding of the policy [23]
Tanzania
Service delivery · No information
Health workforce · No information
Health information · No information
Medical products · No information
Financing · Informal payments [41]
Leadership · No information
Uganda
Service delivery · Increase in utilization [20, 2426, 28, 34]
  · Increase in utilization; decline in service quality [27]
Health workforce · Lower morale of providers [27, 29]
  · Increase in the average number of consultations per provider; negative attitude of providers [22]
Health information · No information
Medical products · Problems of availability of drugs [24, 26, 27, 29, 34]
Financing · Insufficient funding [25, 34]
  · Difficulties in meeting recurrent expenses; informal payments [27]
Leadership · Interference with other types of interventions [27]