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for primary health services (and of course for tertiary care) is the research done by Akin et al. (1986) in the Bicol Region of the Philippines. The Philippines study found that patients are highly insensitive to medical care prices. User fees would therefore affect utilization of medical services very little. The results reported by Jimenez (1989) showing very low price sensitivities to changes in medical care prices in Ethiopia (.05 to .50) and Sudan (.37) lend support to the policy of charging fees for primary health services in Sub-Saharan Africa. A study of Zairean health zones by Bitran (1988) would also seem to support the policy of charging fees at the peripheral health facilities. The study showed that the Zairean health zores were able to finance a significant portion of their recurrent costs with revenue from user fees. No attempt was made to determine the effect of fees on utilization of health services. Demand studies in Swaziland (Yoder, 1989) and in Ghana (Waddington and Enyimayew, 1989) show that after imposition of user fees in government health facilities, visits to peripheral facilities declined drastically. But visits to urban and mission facilities remained the same or actually increased following introduc:ion of user fees.

19. Leaving aside the empirical issue of whether or not the magnitudes of patients' responsiveness to medical care prices reported in the literature are correct, it is worth pointing out that patients' insensitivity to costs of medical care is not sufficient to justify introduction of fees in the now free government clinics. This is because when fees are introduced, patients might have to make unwarranted sacrifices (e.g. selling land, incurring large debts) in order to meet costs of medical care. That is, if fees are introduced for basic health services, poor households might have to forego other basic needs in order to pay for medical services. Studies on effects of cost sharing schemes on health in the United States (Keeler E. et al. (1987)) suggest that those who are sick will often sacrifice other consumption (basic needs) to pay moderate amounts for medical treatment. Such sacrifices are likely to be quite large in low incmrne countries.

20. Patients' insensitivity to costs of medical can; implies that they are willing to trade off some of their basic needs for medical care.<sup>9</sup> Such a tradeoff worsens social welfare because from the pe spective of society, one bsic need should not be satisfied at the expense of another. In brief, there are two reasons why introduction of user fees in primary health facilities would be inappropriate in many Sub-Saharan African countries. First, user fees (unless extremely low and therefore unsuitable for cost recovery) would exclude a significant number of poor households from basic health services. Second, even if user fees were to leave utilization of basic health services unaffected, it is high;y likely that they would force poor households to make sacrifices that would worsen their welfare.

21. The above discussion needs to be re-emphasized because of its policy significance: 9 'The presumption here is that poor people must trade off a basic need (not a luxury) in order to maintain their consumption levels. This because at low levels of consumption, people can hardly afford to buy luxuries.