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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