Health for some?: the effects of user fees in the Volta region of Ghana

This paper, published in Health Policy and Planning, reports findings from a 1996 study of user fees and exemptions for health services in the Volta region of Ghana. The study found that facility managers were very active in setting and collecting fees and in using the revenues to purchase essential inputs. Fee revenues accounted for between two-thirds and four-fifths of the non-salary operating budget of government health facilities, and virtually all of the resources for non-salary operating expenses in mission hospitals. However, exemptions for the poor were largely non-functional: less than one in 1000 patients were granted exemption in 1995.

The paper argues that the failure to ensure that the poor were exempted from user fees meant that the fees were imposing significant hardships on them, or excluding them from the services altogether. It concludes that health facilities in the region have achieved “sustainable inequity,” with fees enabling service provision to continue but preventing part of the population from using the services. Recommendations include reforms to the way fees are collected and changes to prescribing practices. The paper notes that exemption mechanisms are unlikely to work well in their present form, and suggests subsidised risk-pooling systems as a possible way of enabling poor people to purchase services.