As a result, health systems have become less accessible and less equitable …

In practice, these measures led to reduced access and equity in health services, mainly because of the:

  • poor working of exemption mechanisms (leakage of non-exempt groups into free care and groups meriting exemptions not accessing them due to lack of information, excessive bureaucratic demands, lack of formal proof of earnings, etc.);
  • reduced use of care in the poorest groups, associated in some cases with an increase in damaging health behaviour and in ill health;
  • depletion of household assets to meet health costs, increasing expenditure on future health risk;
  • little improvement in quality of care at primary care levels, or of increased budget allocations to these levels;
  • insignificant additional revenue generated;
  • weak or temporary impacts on the use of the referral system without corresponding changes in quality of care (Equinet Steering Committee, 1998).

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