Removing user fees for primary care in Africa: the need for careful action

This paper, published in the British Medical Journal, argues that African countries should move away from user fees for health, and outlines what actions should accompany their removal, drawing on experiences from South Africa, Zambia and Uganda. It argues that user fees are the most regressive form of health financing available and contribute to the unaffordable cost burdens imposed on poor households. Although fees for primary care are relatively low, they can encourage inappropriate self treatment, use of partial drug doses, or act as a barrier to early use of health facilities. They can also contribute to the impoverishment of vulnerable households.

The paper argues that funding must be increased before removing fees. Fee removal is likely to result in substantial and sustained increases in utilisation, which could easily lead to drug shortages, staff difficulties, and falling quality of care. The authors recommend increasing health funding from general taxation, and suggest that this would be made easier if African countries’ debts were cancelled. Practical strategies include: giving a specific government unit responsibility for coordinating fee removal and other actions needed to strengthen the health system; establishing new funds at the local level; public information campaigns; and better planning for drug and staff availability.