Briefing: Abolishing user fees in Sierra Leone
Health Poverty Action published a briefing in the run up to the abolition of user fees in Sierra Leone, highlighting what needs to be done to make it effective. Download it here.
Abolishing user fees in Sierra Leone (942.28 kB)
UPDATE FROM THE FIELD: Click here to find out how the removal of fees for women and children using health centres in Sierra Leone is going.
User fees mean that many people in the world’s poorest countries simply do not seek treatment when they are ill, or delay getting help. This can be fatal for conditions that require urgent attention, such as malaria in children.
Research has suggested that abolishing user fees could prevent over 230,000 child deaths each year, across 20 African countries.
Where they exist in Africa, fees fund less than 5% of the total cost of health services, with significant administrative costs. Although a few countries have historically used fees to fund health, most have come under pressure to do so from international donors such as the World Bank and International Monetary Fund – often as a condition of loans.
The effect of fees
Studies suggest that when fees are introduced, take-up of services drops by an average of 40-50%. For example, use of health services halved in Rwanda when health fees were introduced in 1996. Many countries have seen any health progress reversed by the introduction of fees.
It’s not surprising when you look at the costs. One study has suggested that the cost of giving birth in Sierra Leone is equivalent to six weeks’ income for the average person.
Fees also disproportionately damage the health of marginalised people, pushing families into debt and poverty. They can especially penalise women who have fewer resources to draw upon. And in Cambodia a study also found that the introduction of user fees led to equivalent increases in private sector health costs, pushing costs up for everyone.
Eliminating Fees
Developing countries pledged to move away from user fees at the World Health Assembly in 2005, with wealthy G8 countries agreeing to financially support this.
The World Bank is also now willing to support countries that want to remove user fees from public facilities, provided that the lost revenue is replaced with sustainable, well-managed funds. But only a handful of countries have moved ahead.
The costs of abolishing fees are hard to calculate but simply replacing lost revenue would require about $100-120 million for many low income sub-Saharan African and Asian countries per year.
A bigger question is the cost of increased demand. Zambia abolished fees in 2006, with help from the UK government, and saw an immediate 30% rise in use of health services nationally.
In some countries patients are also asked to pay informal fees, levied by health workers, to boost the income for their clinic or to supplement their own low salaries.
Health Poverty Action says:
- Developing country governments should abolish fees for essential healthcare and choose a system of financing that will best improve access to health services for their most marginalised groups. This should be appropriate to existing institutional structures, culture and traditions, and to their economic development. This could be through taxation with healthcare costs paid for by the government.
- Abolishing user fees is likely to see an increase in the use of services. Rich country governments should provide predictable aid, committed for the long term, to give developing countries the confidence to abolish fees.
- G8 countries in particular should fulfil the promise they made in 2005 to assist countries that would like to end user fees, following the example set by the UK and Zambia. Cancelling the debts of developing countries would also help them increase their health spending.
- The World Bank and other international institutions must stop prescribing user fees to countries as part of official or unofficial policy advice and provide more financial assistance to scrap fees.
- The low pay and poor conditions of health workers must be addressed to stop informal fees being levied.
Learn more about user fees.
Last modified: 12/01/2011
