What are user fees?
User fees are charges made before you can access health services. These charges are in place in most sub-Saharan African countries and many countries of Asia and Latin America.
The type of fees can vary. There may be registration fees when first seeking help, charges for medicine, treatment and diagnostic tests and charges to stay in a hospital bed. In some instances patients have been charged for the rubber gloves that health workers wear.
Patients may need to pay informal fees as well, levied by health workers to boost the income for their clinic or to add to their own low salaries.
What was the original rationale behind user fees?
The rationale was that they would provide extra funding for health systems at a time when aid flows were low, debt repayments were high and many developing country governments were feeling the squeeze on their national budgets. There was also an ideological shift in thinking on health systems in the early 1990s which promoted the idea that getting patients to pay for treatment would help motivate healthcare workers and increase efficiency.
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How have user fees compounded poverty?
Fees disproportionately damage the health of poor and marginalised people. They can push families into debt and poverty, forcing them to borrow money informally or from moneylenders, or to sell or mortgage livestock or assets that they rely upon to make an income. The charges can especially penalise women who have fewer resources to draw on.
The situation can become a vicious cycle where increased poverty results in poorer nutrition and living conditions, poorer health, and even greater problems next time there is a sudden need to pay for urgent healthcare.
The World Health Organisation calculates that 100 million people each year are driven into poverty by these sudden healthcare costs.
When going into hospital becomes expensive, more care is also likely to take place in the home. This increased burden of care usually falls on women and girls – who may have to forgo education or paid employment in order to take on a caring role.
What is current thinking on user fees?
2005 saw a particular change in the debate. 189 countries pledged to move away from their use at the 2005 World Health Assembly, and that summer the G8 group of wealthy nations agreed to assist countries that wanted to stop imposing charges.
The UK government formally renounced the use of fees, with the then Chancellor, Gordon Brown, declaring: “there must be universal and free schooling and healthcare as the beginning of justice for the poorest countries of the world”.
However, such fine words have still to be put into action by other donors. A handful of countries have abolished fees with support from donors, but millions of marginalised people in other countries are not so lucky. In some cases government policies have softened, with exemptions for under fives, for instance, but these are not always observed, and many people are unaware that they are exempt.
Abolishing user fees could be a ‘quick win’ to speed up progress towards the health Millennium Development Goals.
What examples are there of abolishing user fees?
Abolishing fees has made a striking impact in countries such as Uganda and Zambia.
When Uganda made its public health services free of charge in 2001, against the advice of the World Bank, the use of outpatient care facilities leapt by up to 90% across the country after a period of adjustment.
Likewise Zambia – which had introduced fees in the mid 1990s – abolished rural healthcare fees with support from the UK government in 2006. The result was that use of health services went up by 30% nationally and by 100% at some clinics. The UK government has also supported Burundi and Ghana to end user fees.
Last modified: 13/01/2011
