EXISTENCE OF CLIENT FEES IN THE PUBLIC SECTOR FOR CONTRACEPTIVE OR OTHER
REPRODUCTIVE HEALTH COMMODITIES
Definition:
The existence of client fees in the public sector for family planning (FP) methods or other reproductive health (RH)
commodities. A client fee is the price clients are asked to pay for FP or other RH commodities.
Data Requirements:
Official financial policy documents for contraceptives; evidence of fee scale for FP methods or other RH commodities at
service delivery points
Data Sources:
Administrative records; contraceptive price lists; client exit interviews
Purpose:
This indicator documents if a program is using fees to generate revenue to support the FP program. From the client
perspective, client fees can dis-incentivize FP use if they are too high, promote inequity in FP use between those who
can afford to pay and those who cannot, and – through price differentiation – encourage the use of particular
contraceptive methods over others. From the program perspective, however, client fees can be a reasonable mode to
cost recovery and program sustainability. And the literature shows that the desire to limit and/or delay pregnancy can
outweigh any disincentive to paying fees for contraception, especially if the fees are at a culturally reasonable price
(Hennink, 2005). Furthermore, studies indicate that continuation rates do not decline when client fees are introduced
and in fact, contraceptive use rates often remain the same even after moderately priced services are introduced. Other
experiences indicate that introducing fees may actually improve the quality of services and make the client a more
responsible contraceptive user (Barnett, 1998). However, it is important to consider the impact of user fees on the very
poor and consider implementing exemptions for people who cannot afford to pay.
Despite the controversy over client fees, some countries are instituting fees as the demand for FP and RH services
continues to increase, with governments and donors finding it increasingly difficult to cover the costs of providing
these services. Still other countries are removing user fees to make FP/RH commodities and services more universally
accessible. It is important to consider the reasons for collection of fees, client affordability, and client perception of
quality issues. Documents are available to assist with systematically thinking through these issues (Management
Sciences for Health).
Issue(s):
This “yes/no” policy indicator is problematic because it does not does leave room for nuance or explanation. There is
no indication of what fees are being charged, whether they are different and/or reasonable for the population being
served (for example, rural versus urban service delivery point fees), whether and how they differ per method, and/or
to what extent they are actually enforced. Also, this indicator does not reveal incentives (either through contraceptive
price differentiation and/or payments to acceptors), which can be controversial when there is coercion and/or
encouragement to use certain methods, or helpful when they are used to overcome constraints to FP use (for example,
to reimburse client travel costs). Furthermore, if there are, in fact, client fees in the public sector for contraceptive or
other RH commodities, this indicator does not describe whether there exist exemptions or a sliding scale for those who
cannot afford to pay, nor does it give information regarding policies in the private sector. Finally, this indicator
examines whether there are fees related to the provision of the commodities, but does not investigate whether there
are service-related fees. Based on this indicator alone, the impact of this operational policy cannot be determined and
additional research would be required.
Poverty and Equity Considerations:
Compared to other areas of health spending, the poor are proportionally higher consumers of public health goods and
services (depending on the location of service delivery and other factors affecting access). When government's take on
a greater responsibility for public health spending, this directly contributes to poverty reduction through improved
health status and protection from catastrophic losses due to treatment costs (Becker, Wolf, Levine, 2006).
Gender Implications:
Often the control of household financial resources lies with men (sexual partners, husbands, fathers, and other male
relatives). The existence of client fees for contraceptive or other RH commodities can make services prohibitive to
women who do not generate their own income or cannot access other financial resources without male consent.
References:
Barnett, B. “Do client fees help or hurt?” NETWORK 18(2):6-7, 9, 11. 1998.
Becker L, Wolf J, Levine R, 2006. MEASURING COMMITMENT TO HEALTH. Center for Global Development.
http://www.cgdev.org/doc/ghprn/Final%20Indicators%20Consultation%20Report.pdf
Family Planning Management Development. Charging Fees for Family Planning Services. THE FAMILY PLANNING
MANAGER: MANAGEMENT STRATEGIES FOR IMPROVING FAMILY PLANNING SERVICE DELIVERY 1(3). 1992.
Management Sciences for Health.
Hennink M, Madise N. Influence of user fees on contraceptive use in Malawi. AFRICAN POPULATION STUDIES
2005;20(2):125-41.
USAID | DELIVER PROJECT, Task Order 1. 2010. MEASURING CONTRACEPTIVE SECURITY INDICATORS IN 36
COUNTRIES. Arlington, Va.: USAID | DELIVER PROJECT, Task Order 1.