Household Coping Strategies in Response to the Introduction of User Charges for Social Services: A Case Study in Uganda

Abstract

This study examines approaches to health care seeking and financing by households living in communities in two poor rural districts of Uganda. It seeks to explore differences in the choice of provider and methods of funding care between the two districts, and the economic circumstances and social attitudes which influence these differences. It considers the impact on households budgets of health care charges, both at public facilities (licit and illicit) and by private sector providers. Qualitative fieldwork was used to determine attitudes to the introduction of user charges, the extent to which they have influenced health care seeking behaviour and whether attempts by households to find sustainable coping strategies, either individually or through community organisations, have been successful in ensuring adequate health care for all their members. The research raised issues as to the appropriate definition of utilisation of services in circumstances where profession staff are often substituted by 'assistants' and drugs are frequently prescribed in public facilities but then have to be purchased from private suppliers. It stresses the relative autonomy of facility staff and constraints on effective supervision. Under these circumstances there is room for considerable confusion between sanctioned user-charges and illicit demands by providers. Many households face difficulties with what they see as a multiplicity of demands for cash payments, of which education and health charges are a major component. Community organisations do not appear to make a major direct contribution to meeting such charges. However, community based savings and credit societies, where they exist, appear to play a central role in overcoming seasonal fluctuations in cash availability. Making these more accessible to poor households or developing effective and sustainable systems for providing services on credit might alleviate current problems.