Table of Contents

Case Scenario
Case Discussion Questions
Case Analysis

Case Scenario

Mr. Ngao, the regional field supervisor for government family planning services, greeted the eight clinic managers he supervised and presented the agenda he had posted on the wall.

"At our meeting last month," he began, "we discussed the pilot project that the Ministry of Health is planning to launch to test the feasibility of charging for family planning services. Yesterday, I was informed by the Ministry that our region has been selected as a site for this pilot project. When we spoke about introducing fees last month, some of you were worried that charging for family planning services might discourage people from coming for family planning services. I know that charging for services is a sensitive subject, but we have been asked by the Ministry for some ideas on how to introduce fees."

The clinic managers were silent for a minute. Mrs. Atieno was the first to speak. "Government services have always been free. I think it's wrong to ask people to pay for family planning services."

Mrs. Mwangi straightened up in her chair. "That's one view, but we are providing a valuable service. People often place more value on things if they pay for them, even if it is only a small amount. If they pay for contraception, I think that people might be more likely to use it."

"I agree with you," said Mr. Kibunga, "but some clients are really too poor to pay. Couldn't they be exempted from paying?"

"The clients at my clinic have some money at harvest time but eventually run out of cash," said Mrs. Awiti. "Perhaps we could waive the fee for them during those seasons when they are short of money?"

"We could suggest to the Ministry a system of waiving fees or exempting certain clients who can't pay," Mr. Ngao replied. "We would have to come up with criteria for identifying clients who could not pay."

"At our clinic some of our clients are able to pay and are also very busy," said Mr. Thuo. "These kinds of clients might be willing to pay for a fixed appointment if they didn't have to wait."

"Perhaps we could offer our clients the option of scheduling an appointment. We could charge more for appointments than for walk-in clients," said Mr. Ngao.

"I think that system would be difficult to implement," commented Mrs. Atieno. "I think that developing a sliding fee scale, which sets fees based on client income levels and family size, might be a more practical option. I'd like to understand better how the system would work and how we would administer it."

Mr. Ngao then asked his managers to prepare a plan that included: the information that would be needed in order to decide what to charge for, who to charge, and how much to charge; administrative changes that would be needed to charge fees; and steps that each clinic manager should take before introducing client fees.

Case Discussion Questions

1. What factors should Mr. Ngao's managers consider in deciding what kind of services to charge for, who to charge, and how much to charge?

2. What kind of administrative changes will be required to introduce client fees?

3. What steps should be followed before introducing client fees?

Case Analysis

1. What factors should Mr. Ngao's managers consider in deciding what kind of services to charge for, who to charge, and how much to charge?

Mr. Ngao and the eight clinic managers should gather information on such things as the:

• Ministry's objectives for charging fees;
• clients' ability to pay;
• clients' willingness to pay;
• client perception of the quality of current services;
• services which clients would be most willing to pay for;
• estimated cost of providing services;
• cost of new administrative procedures required to introduce fees.

2. What kind of administrative changes will be required to introduce client fees?

The administration of any fee system will require developing new administrative and financial procedures for handling the fees that will be collected. These include development of internal financial controls to ensure that money received is properly accounted for and productively used. In addition, waiver and exemption policies should be developed. After a detailed assessment, Mr. Ngao's managers need to clearly define the administrative procedures required for:

• collecting fees;
• handling cash;
• accounting for cash;
• reporting income and expenses;
• implementing a fair and flexible system of waivers and exemptions.

3. What steps should be followed before introducing client fees?

Mr. Ngao's clinic managers might consider some of the following activities in preparation for introducing client fees:

• Explain the new program to the staff and describe the benefits that can be expected from charging fees for services.
• Let clients know well in advance that a new system is being introduced.
• Make sure that both staff and clients know what the fees are being used for, and then make sure that the income from the fees is used for the purposes and improvements that were promised.
• Train staff in new financial procedures and then implement a fair and flexible system of waivers and exemptions.
• Discuss with staff how to manage potential complaints from clients about the fees.
• Consider what kind of drop in client attendance would be acceptable as a result of introducing fees. Decide what action to take if the decline is greater than expected.
   
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