User charges in public health facilities in Tanzania: effect on revenues, quality of services and people's health-seeking behaviour for malaria illnesses in Korogwe district.

User charges in public health facilities are aimed at improving efficiency and quality of health services. In Africa, evidence about their effect on patient attendance and community health-seeking behaviour are mixed. This paper reports a study of the effect of user charges on revenue collection, quality of services and people's health-seeking behaviour in relation to malaria in Korogwe district, Tanzania. Data were collected through focus-group discussions with community members, interviewing community leaders and health workers, field observations and review of patient registers. Generally, there was no distinct difference in the trends of patient attendances before and after user fee introduction. Public awareness about cost-sharing policy was high, but had low appreciation in the administration of exemptions and waivers. Shortage of drugs, laboratory facilities, and inhospitality of nurses lowered their confidence in the user-fee system. Autonomy to collect and prioritize expenditure of user-fee revenue at the health-facility level was appreciated by community leaders and health workers who, however, had reservations with funds being held at the district level and delays by the DMO's office in approving budgets submitted in request for expenditure of such revenues. Thus, despite the potential of user charges for revenue mobilization, problems with their administration lowers public confidence in the user-fee system improving quality and accessibility of services to the poor.