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This issues paper, published by the DFID Health Systems Resource Centre (HSRC), was one of several feeding into Department for International Development (DFID) policy discussions in mid-2004.It examines evidence on the impacts of user fees for primary health care, evaluates the cost implications of abolishing user fees, and considers what line donors should take on the issue.The paper argues that the case for abolishing user fees is strong: they raise little money, rarely meet their stated efficiency and equity goals.They are often associated with reduced use of services, especially by the poor and vulnerable; failure to complete treatment; and delays in seeking treatment.However, the paper also claims that there are some circumstances in which user fees can improve access.

The paper recommends that removing fees needs to be accompanied by a range of actions including increased and well directed funding if it is to lead to sustained improvements in access for the poor. It also suggests that user fees may be a relatively minor issue in terms of the whole poverty reduction agenda, and that it may be more useful for DFID to push a broader line, such as making essential services more affordable for poor people. Other recommendations for donors include considering tactical as well as technical issues in deciding what approach to take.

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