Willingness to pay for child survival: Results of a national survey in Central African Republic

Many policy-makers and health economists are interested in designing and implementing user fee/quality improvement programs in public facilities in Sub-Saharan Africa on a national scale. This research addresses two design issues for a national program: (1) to what extent would user fees finance the costs of quality improvements, and (2) whether a uniform program could be implemented throughout the country or the user fees should differ between urban and rural areas or across health regions. A national survey was conducted to determine the population's willingness and ability to pay for seven quality improvements: (1) facility maintenance, (2) supervision of personnel, and drugs to treat (3) diarrheal diseases, (4) acute respiratory infections (ARI), (5) malaria, (6) intestinal parasites, and (7) sexually transmitted diseases (STDs). Willingness to pay for quality improvements was measured by contingent valuation techniques in which subjects were asked about expenditures for care at government facilities under a hypothetical user fee/quality improvement program. Ability to pay was measured by monthly expenditures for health care as a percentage of monthly household consumption. The majority of the population was willing to pay the cost of the quality improvements, which ranged from U.S. $0.40 to U.S. $4.00. Estimates of the percentage of the population that was willing to pay the cost of the quality improvements ranged from 81% for facility maintenance (an improvement with the lowest cost) to 64% for drugs to treat ARI (the improvement with the highest cost). The median willingness to pay ranged from U.S. $7.98 for drugs to treat malaria to U.S. $16.61 for drugs to treat diarrheal diseases. Willingness to pay was greater in rural areas than in urban areas. It was also greater in Health Region I than in Health Regions IV and V. The population was able to pay the estimated cost of all seven quality improvements. Median monthly health care expenditures per episode of illness was 2.6% of median monthly household consumption. In comparison, the estimated cost of the quality improvements ranged from 0.2 to 2.4% median monthly household consumption. The national user fee/quality improvement program has good prospects for financing the quality improvements because the majority of the population is willing to pay the estimated costs of the quality improvements and more than half of the population is willing to pay substantially more than the costs. It also appears that the user fees should differ between urban and rural areas and across some health regions.