Inequalities in Access to Health Care in Zambia after the User Fee Removal in 2006

In April 2006 the government of Zambia removed user fees for primary health care in public health facilities in rural areas in Zambia. The goal was to improve equity in access to health care, because the poorest segments of the population (mostly living in rural areas) could not afford paying the user fees for health care. Several studies have shown a dramatic increase in health care use in rural areas after the user fee removal, especially in the poorest regions of Zambia. This has led to supply side problems; some health facilities were not able to treat all new patients. There are also signs that still other barriers in accessing health care exist preventing the poor population from getting treatment. This research aims to describe the distribution of access to health care between poor and rich in rural areas of Zambia after the user fee removal. The Demographic and Health Survey of Zambia from 2002 and 2007 were used to perform several inequality analyses and a Difference-in-Differences estimation concerning the following topics: health facility visits by women, barriers in accessing health care experienced by women, receiving free medical care by households and skilled attendance during delivery. Results showed less rural women visiting health facilities in 2007 when compared to 2002. Even though the financial barrier decreased, other barriers - especially the availability of drugs, transport and distance - in accessing health care were still experienced by many women living in rural areas. While these barriers reduced over time for the women in richer quintiles, they remained at the same level for the poorest women. Results also showed that the user fee removal did not have a significant effect on skilled birth attendance. Access to health care has become even more unequally distributed and is more concentrated amongst the rich after the user fee removal when compared to 2002.