How to abolish user fees

Removing user fees without doing anything else may make the situation worse. What steps are needed to ensure that the situation for local health centres does not deteriorate as a result? The following policy recommendations have been made:

Increase funding:

Removing user fees leads to a large increase in the use of health services, which could lead to drug shortages, staff difficulties, and falling quality. Funding therefore has to be increased to a level which not only compensates for the loss of fees from existing users, but also allows the system to cope with an influx of new users. Removing user fees for primary care in Africa argues that donor funding might help to do this, but should be used cautiously because it is unreliable. Instead, the money should come from general taxation.

Well-directed funding:

The increase in service use that follows fee removal is likely to be greatest in poorer areas, and so these areas will need the largest injections of new funding.

Decentralise:

The positive experience with user fee abolition in Uganda has been attributed partly to the decentralisation of budgets and power to community levels during the 1990s. Strategies could include establishing locally controlled operational funds for small scale funding decisions.

Develop a communications strategy:

Communication between senior managers and local level health workers is needed to elicit good ideas about how to implement the policy effectively, and to improve acceptance of it. Public information campaigns are also needed to ensure the general public knows about the change – otherwise health workers may continue to charge fees.

 

Other recommendations include:

• addressing financial management problems, such as paying staff on time and releasing budgets in a timely manner
• improving drug supply and procurement systems, and making provisions for the increased demand for drugs which is likely to follow the removal of fees
• increasing the pay of health workers in order to improve productivity
• monitoring the impact of the policy change closely.