User fees

This User fees key issues guide examines the evidence on the impact of user fees and presents some of the on-going debates relating to health financing policies. It considers arguments for and against abolishing fees, and provides recommendations on how fees should work if they are kept.

User fees for health care, also referred to as cost sharing, cost recovery or co-payment, are widespread around the developing world, despite mounting opposition to them. Many studies have found them to be among the barriers to the use of health services, and have shown that they affect poor people more than others.

Such concerns have led many researchers, advisers, and policy makers to question whether user fees should be applied, especially among poor and vulnerable groups. In particular, there is concern that user fees will hinder access to essential social services and so prevent the Millennium Development Goals from being met.

Yet there are reasons to be cautious about abolishing user fees. They are rarely the most important barrier to using health services, and abolishing them would remove a relatively small, but often important source of funding for primary health facilities. Unless this funding is replaced from other sources, there could be adverse consequences for quality of service. User fees may also be a necessary part of other mechanisms for financing health care, such as insurance schemes. They therefore have to be seen within the broader context of health systems financing.

Background

In many African countries, user fees were first implemented through the 1987 Bamako Initiative. The history and effects of this initiative are outlined. The section also considers the World Bank's policy on user fees and the effect of user fees on the Millennium Development Goals. More...

Experiences

The following sections review the experiences with user fees in achieving each of the seven goals of user fees identified in Charting the path to the World Bank's "no blanket policy" on user fees.  They appear to have raised less revenue than expected and have acted as a disincentive for both poor and non-poor people to use health services. More...

Ways forward

This section discusses whether user fees should be abolished, if so how they should be abolished, and if they are kept, how they should be designed and implemented. It also discusses what stances donors should take. More...