Influence of User Fees on Contraceptive Use in Malawi

The introduction of cost-sharing strategies such as user-fees for health care in developing countries has received increasing attention due to declining government expenditure on health and reduced donor funding. Many governments of developing countries face the dilemma of introducing fees for family planning services while maintaining contraceptive prevalence rates. This study conducted 16 focus group discussions with poor communities in urban and rural areas of Malawi, to identify their views on the affordability of contraception and the perceived effects of user fees on their contraceptive use. The results show that amongst poor communities the long term health benefits of contraception are considered to be greater than a marginal increase in the cost of methods. An increase in the cost of temporary methods was seen as bearable, while financing permanent methods was seen as more problematic. The introduction of user-fees for family planning at government facilities would need to be accompanied by an increase in the quality of services provided to be acceptable. Those most likely to be affected by user fees are rural residents, for whom targeted assistance may be required to maintain contraceptive use. The introduction of user-fees with a subsidised treatment option was the most feasible strategy. However, the difficulties in determining eligibility for the subsidies are a critical issue. Results highlighted that the application of broader eligibility criteria are needed to account for social and non-monetary indicators of poverty in conjunction with economic indicators.