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Table 4 Synthesis of pressures mentioned in the literature (1988 to 2009)

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

Health system functions Pressures on the health system
Service provision Increase in service utilization and in the demand for services
Health personnel Increase in workload, increase in the patient/provider ratio, insufficient medical staff
  Loss of income
  Lack of time for consultations
  Feeling of being exploited, frustrated, overworked
  Negative attitude of providers
  Deterioration in staff morale
Health information Lack of information on the number and type of services carried out in the health centres and on the amount of reimbursements.
Drugs and vaccines Problems of availability of drugs
  Insufficient drugs and kits to meet local needs
  Delays and under-distribution of consumables
Funding Funding unpredictable, insufficient and discontinuous
  Loss of income for health centres and increased debt
  Problems with reimbursements for cases of referrals
  Reverting back to charging for services and drugs
  Insufficient funding
  Service providers having difficulty paying recurrent expenses
  Delays in reimbursements
Governance and leadership Poor planning and communication; poor understanding of the policies
  Inadequate supervision
  “No blame” game and problems in obtaining accounting reports and in assigning responsibilities for acts
  Complexity of funding procedures
  Interference with other health policies and programs