Are people willing and able to pay for health services?

Following a nationwide increase in user fees for health services in Swaziland, this paper analyzes the effect of the fee increase on overall patient use of health services, on which types of services, curative vs preventive, were most affected, and on changes in utilization by higher paying and lower paying groups. Patient attendance data from a 71% sample of government and mission health facilities, suggests that the 'people are willing and able to pay for health services' assertion is not supported by the Swaziland case. Following the fee increase, average attendance decreased at government facilities by 32.4%, increased at mission facilities by 10.2%, leading to a combined decline of approx. 17%. Patient visits designed to protect against childhood diseases, BCG and DPT immunizations, or against dehydration in children, show average attendance declines of -16, -19, and -24%, respectively, while visits for musculoskeletal diseases, a less serious disease, declined 1.2%. The analysis also suggests that up to 34% of the overall decline in attendance was among patients who previously had paid the least for health care with part of this decline likely including fewer multiple visits.