Uganda's experience with abolishing user fees.

Health user fees were abolished in Uganda in 2000. A World Bank report compares selected indicators before and after the abolition of user fees in Uganda. The results show improved access and increased use of services, less work days lost due to sickness, and a tendency for wealthy households to opt out of public services. The figure below shows the trend in monthly outpatient rates in Kisoro District, a trend which was reflected across virtually the whole of Uganda.

View: Outpatient attendance before and after removal of user fees in Kisoro District, Uganda

Nationwide, the number of new cases treated by health centres increased by 19 per cent for children under five and 31 per cent for the rest of the population. Referrals increased by 26 per cent. Monthly attendance figures are considerably higher now, although they vary according to drug availability: when the drugs run out attendance rates drop. However, these outcomes are significantly better than those predicted by the World Bank, which predicted an increase in utilisation of around 2 per cent.

However, the impacts on illness reporting, use of preventive services, and quality appear to have been limited. Drug stocks have run out more often, due partly to increased demand for services and the inability of the supply system to react to this increase. There were also some delays in fund disbursement from central level. A WHO study reports that health workers felt morale had declined after fees were abolished, and many health unit management committees stopped meeting regularly.

Despite these shortfalls, user fee abolition has been considered a success in Uganda. The country avoided falling back into the situation of fund-starved, centrally administered health services, which led to the introduction of user fees in the first place. This success has been attributed mainly to political decisions to increase the health budget and replace the lost user fee revenues with additional funding. Great efforts were undertaken to broaden the tax base, and donor budget support also increased.

A second factor credited for Uganda's success is its efforts to decentralise budgets during the 1990s. Management Committees, which had become active in the co-management of community level health centres through their role in administering user fees, remained in place but were allocated tax-funded government budgets instead.

See also: Free government health services: are they the best way to reach the poor.