User fee programmes can have positive effects, such as increasing access to essential drugs and improving rational use of drugs. But user fee programmes can also have negative effects, such as reduced access to treatment and reduced public expenditure for health. When embarking on a new user fee programme or when making significant changes in an existing programme, it is essential that the effects of the programme be carefully monitored. The following questions should always be asked in monitoring the cost-sharing programme:

• Revenue generation - Are cash and insurance revenues generated as expected from service volume?

• Revenue expenditure - Is the expenditure spent according to guidelines, 75% for the facility and 25% for public health care expenditure?

• Quality impact -Is quality of service improving?

• Equity effects - Are people being excluded from essential health services because of fees? Or are households worse off because of fees?

• Budget impact - Is fee revenue supplementing or substituting for central Treasury expenditures?

Experience from monitoring user fee programmes in Africa and Asia indicates that four types of monitoring methods should be used together: (1) field supervision, (2) routine reporting, (3) sentinel systems, and (4) special studies. Each type of monitoring provides different information and has different resource requirements.

Country priorities for drug financing

Participants from each country identified the following main concerns and/or problems as their priorities:

• To increase the health budget as well as the drug budget.

• Inadequate financial support for drugs from Government. How to reduce irrational drug use (financial mechanisms to improve use and reduce cost)?

• Lack of coordinated effort among all nongovernental organizations (NGOs), and the public sector.