A free for all? Removing health user fees in Africa

Charging patients for basic health care hits the poorest members of society the hardest. Many fall into debt or simply do not seek care from public health services. The Commission for Africa has called for basic health care to be free for everyone. How would this impact on already under resourced health services?

Chargingpatients for health care may encourage poor people to treat themselves withtraditional medicines or with drugs bought from a peddler instead of attendinga clinic. Often courses of treatment will not be completed due to the cost ofthe drugs. Medical fees were introduced in the late 1980s and early 1990s inmany African countries in response to pressure from the World Bank and theInternational Monetary Fund to cut public funding of social services. It isencouraging that fees are now being removed in a growing number of Africancountries, but this should be carried out without harming health services.National health budgets will have to be increased to meet increased demand oncethe services become free.

Analystsfrom the Universities of Witwatersrand and Cape Town looked at the experiencesof South Africa and Uganda, where medical fees have been removed, as well asother experiences of implementing changes in financing policies, to discoverwhat lessons can be learned. The analysis indicates that policy changes such asfee removal have problems because:

• policies were pushedthrough too quickly due to political pressure without sufficient thoughtand planning
• ministers of healthdirectly intervened to support or oppose specific policies, without clearreference to relevant evidence
• technical analysts, withthe expertise necessary to support decision-making, did not have the poweror the links with government to push through policy
• governments do notcommunicate enough with the public or health workers about new policies
• not enough drugs or staffare put in place to cope with increased demand
• there is not enough monitoringof how new policies affect clinics, staff and patients.

Governmentsshould learn from the lesson of past experience in planning for fee removal.The task of coordinating all the actions necessary to remove fees and implementthe actions necessary to strengthen health service delivery should be given toa specific government unit. In order to carry out fee removal successfully, itis necessary to:

• start a nationwidecampaign, before the policy change, by means of radio, newspapers, postersand meetings with village elders in order to let the public know what toexpect
• communicate clearly withhealth workers about the goals, as well as when and where changes willtake place, through meetings, visits and newsletters
• decentralise some portionof budgets to allow health managers to make small-scale spending decisions
• make sure there areenough drugs and staff to cope with the increased demand at health centres
• improve access to healthservices, for example build more clinics and introduce more health workersbased in the community
• encourage feedback from healthworkers about their experiences in introducing the changes.