Goal 4: decentralisation and sustainability

An appropriate pricing structure could encourage the use of district-based health facilities close to the home of the patient, rather than more distant tertiary (specialist consultancy) centres. If user fees are kept at the point of collection, this would increase resources and spending at lower levels of the system, improving their sustainability.

User fees have had some success in making local services sustainable

The evidence suggests that user fees have been considerably more successful in reaching this goal than in most of the others. More and better services have been provided at the primary care level. Key quality indicators such as availability of drugs have particularly benefited (see, for example, Assessment of Niger's national cost recovery policy implementation in the primary health care sector).

However, a possible side effect of user fees is that central government becomes less concerned with financing at decentralised levels. In general, governments tend to spend a large proportion of their budget at the central ministerial level and in national "flagship" hospitals and referral hospitals, except where there have been special drives (usually with donor backing) to decentralise spending as in Uganda, Ghana, and Tanzania.

Access to basic social services contends that user fees are often used to substitute for funding from central government. Results from Zambia suggested that provision of some key service shifted away from hospitals towards health centres after the introduction of user fees, although for overall outpatient services this trend was not so evident, and the most striking effect was a large drop in attendance at both types of facility. Priority service provision under decentralization reports that local revenue was not increased significantly by user fees for maternal and child health services, because many people were reluctant or unable to pay the fees, and the revenues raised went to the district level for reallocation elsewhere.