A price to pay, part 2: The impact of user charges in the Volta region of Ghana

This paper looks at what happened in Ghana following increases in government health service charges in 1983 and 1985. A combination of analysis of records, interviews and discussion with community groups was used. Utilization in rural areas was affected drastically by the substantial increase of 1985. The effect on urban utilization was less extreme and less durable. The age composition of users changed. After the 1985 increase, proportionately more of the 15‐45 age group used the government services—this was particularly at the expense of the over‐45s. The population was obviously concerned with the cost of health care, but were even more concerned about the quality of care and receiving value‐for‐money. They were unwilling to pay if drug supplies were unreliable or staff behaved unpleasantly. Some problems were encountered with implementing the policy of charges. Many facilities did not spend the revenue to which they were entitled—an interesting point, as the existence of the skill to spend money is often tacitly assumed! Charges also had significant indirect resource consequences. Reduced utilization freed up staff time which should be used to provide other services, particularly preventive ones. This opportunity has not, as yet, been exploited. Fee revenue can be dangerously attractive, particularly if it is administratively more accessible than general government allocations. There is a danger that revenue collection becomes a disproportionately important evaluative criterion in a system which is, after all, ultimately intended to improve health status.