Donor policy

What stance should donors take on user fees? Opponents of user fees have called for rich countries to stop making user fees a condition for support and to allow developing country governments to judge for themselves whether the fees are an appropriate mechanism.

NGO pressure in the United States brought about a Foreign Aid Bill in 2000 which forced the International Monetary Fund and World Bank to stop imposing user fees as a condition of loans. Advocacy organisations have also called for increased budget support and debt relief in order to make scrapping user fees a genuine option (e.g. Killer bills: make child poverty history - abolish user fees).

The UK Commission for Africa report takes a similar line, recommending that governments abolish user fees, and that when this is done, donors should make a long-term commitment to fill the financing gap until countries can take on these costs themselves. The line taken by G8 leaders at the 2005 Summit at Gleneagles, was slightly weaker, pledging support for "our African partners' commitment to ensure that by 2005 all children ... have access to basic health care" and noting that this may include free services "wherever countries choose to provide this". The World Bank has adopted a pragmatic "no blanket policy"

Many advocacy organisations would like to see donors moving towards a stronger, straightforward stance against user fees. But it has also been argued that this would be unhelpful in cases where developing country governments are unable or reluctant to abolish fees, or where removing fees could make things worse unless a range of other actions are taken at the same time.

The case for abolition of user fees for primary health services argues that user fees are a relatively minor issue, especially given the importance of other barriers to acess to health care, and recommends that donors adopt a broader and more nuanced stance, such as supporting developing countries in their efforts to make essential services affordable for poor people. It also suggests that donors could place more emphasis on other, more important revenue sources. For instance, they could push for African governments to fulfil their commitments under the 2001 Abuja Declaration, to allocate 15 per cent of their budgets to health.