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. In general, they appear to have raised less revenue than expected; have acted as a disincentive for both poor and non-poor people to use health services; and have not led to the degree of community participation envisaged under the Bamako Initiative. In addition, exemption mechanisms for the poor or very poor have in most cases failed, and there is mixed evidence on whether they have improved efficiency or quality.

Evidence does point, however, to some positive impacts. These include increased availability of drugs and medical supplies, which in turn have a positive impact on people's willingness to pay for health care. This has led to increased use of health services in some settings. In many cases, user fees are the main way of maintaining some liquidity (readily usable cash) in the lowest tiers of the health system, thus acting as essential life blood to these systems.