Decreed exemption schemes

In many developing countries, user fees were promoted in the early 90’s as a strategy to generate resources for public health facilities. It was hoped that user fees could improve access to health care services by allowing extra investment and allocation in the health system (e.g. for drug availability) and by empowering patients to raise their voice (the principle of community participation).

Evidence suggests that user fees impede access to health care for many poor people. In order to preserve equity in access to care, most governments simultaneously decreed exemption mechanisms for the poor. Results are mixed and highly debated in a number of papers. Waivers and exemptions for health services in developing countries provides a good overview of different approaches in different countries. It shows that waiver and exemption mechanisms are generally ineffective in increasing access for the poor in most countries, particularly in the poorest ones. This is a result of several factors including bad design, lack of financial compensation to providers, administrative costs and lack of clear criteria for identification. The few positive experiences (e.g. Thailand, Indonesia) have provided appropriate response to these issues.

The general incapacity of exemption and waiver mechanisms to reduce the negative effects of user fees has meant that the debate on user fees remains on global and national agendas. A number of organizations have called for the abolition fees, preferring instead insurance mechanisms or subsidised waiver systems.