Effect of removing user fees on attendance for curative and preventive primary health care services in rural South Africa

User fees are used to recover costs and discourage unnecessary attendance a t primary care clinics in many developing countries. In South Africa, user fees for children aged under 6 yea rs and pregnant women were removed in 19 94, and in 1997 all user fees at all primary health care clinics were aboli shed. The intention of these policy changes was to improve access to health services for previously disadvantaged communities. We investigated the imp act of these changes on clinic attendance patterns in Hlabisa health distri ct. Average quarterly new registrations and total attendances for preventiv e services (antenatal care, immunization, growth monitoring) and curative s ervices (treatment of ailments) at a mobile primary health care unit were s tudied from 1992 to 1998. Regression analysis was undertaken to assess whet her trends were statistically significant. There was a sustained increase i n new registrations (P = 0.0001) and total attendances (P = 0.0001)for cura tive services, and a fall in new registrations (P = 0.01) and total attenda nces for immunization and growth monitoring (P = 0.0002) over the study per iod. The upturn in demand for curative services started at the time of the first policy change. The decreases in antenatal registrations (P = 0.07) an d attendances (P = 0.09) were not statistically significant The number of n ew registrations for immunization and growth monitoring increased following the first policy change but declined thereafter. We found no evidence that the second policy change influenced underlying trends. The removal of user fees improved access to curative services but this may have happened at th e expense of some preventive services. Governments should remain vigilant a bout the effects of new health policies in order to ensure that objectives are being met.