Abolition of user fees

The debate over the abolition of user fees has received much attention following almost two decades of impeding effects on access to health care from the “user fees + exemption” policy, applied in most low- and middle-income countries. The abolition of user fees is strongly supported by a number of influential organisations including DFID, Save the Children UK, the United Nations Millennium Project, the Commission for Africa and Médecins Sans Frontières. Despite this, the number countries that have abolished user fees is small (mainly Uganda and South Africa).

The rationale for abolition is appealing. Issues paper: the case for abolition of user fees argues that user fees raise little money and rarely meet their stated efficiency and equity goals. Fees are often associated with reduced use of services, especially by the poor and vulnerable; failure to complete treatment; and delays in seeking treatment. However it underlines the high costs needed to maintain quality of provision after user fee abolition.

In Removing user fees for primary care in Africa: the need for careful action Gilson et al. call for a comprehensive set of accompanying measures to be applied before abolition in order to avoid negative effects on the health system. In Understanding the impact of eliminating user fees: utilization and catastrophic health expenditures in Uganda the authors demonstrate that although utilisation of health services by the poor significantly increased after the abolition of user fees, the incidence of catastrophic health expenditure among the poor did not fall. This is most likely a result of the unavailability of drugs at government facilities.

Pre-requisites for successful abolition of user fees include careful preparation and appropriate accompanying measures in the fields of complementary funding sources, aid budget allocation, political leadership, providers’ involvement, salary boosting, communication to the population, data collection and consideration of non-financial barriers on access to health care.