Why the international community should eliminate user fees in developing countries.

By Meredy Throop, Policy and Advocacy Coordinator at PIH

“User fees raise less than five percent of a health sector’s budget… most of that income is lost to administrative costs. To be short: fee-based health care is inequitable. If we were to remove these fees, 233,000 children in 20 African countries would be saved from preventable deaths this year.”

                                                                                    - Robert Yates, UK DFID

	A mother and her baby visit a clinic in Rwanda, where PIH covers user fees for poor patients.

Nobody believes that a woman should die in childbirth or that anyone should suffer from a debilitating disease simply because they are too poor to afford health care. Yet this is precisely what happens when small point-of-service fees are charged at public health facilities in low-income countries. 

On April 7, 2011 Partners In Health co-hosted a seminar titled “Health Financing for Universal Access” at the Harvard Kennedy School of Government’s Institute of Politics with Dr. S.A.S. Kargbo from the Sierra Leone Ministry of Health, Robert Yates from the UK Department of International Development (DFID), and Dr. Cristian Baeza from the World Bank.

The event was moderated by Dr. Paul Farmer and Dr. Agnes Binagwaho, Rwanda’s Permanent Secretary of Health. Other co-hosts included the Department of Global Health and Social Medicine at Harvard Medical School, the Center for Global Health at Massachusetts General Hospital, and the Francois-Xavier Bagnoud Center for Health and Human Rights at Harvard University.

The seminar sent a strong message to attendees: the time to abolish user fees is now.

When Robert Yates first began working in Uganda’s Ministry of Health in the 1990s, development discourse mandated user fees for health and education. Yet when Uganda abolished user fees at public health facilities in 2001 against the advice of its donors, outpatient visits nearly doubled.

Within weeks hundreds of thousands of people emerged from the shadows of their deathbeds with a powerful lesson for Yates: it is better to have people waiting in line for treatment than waiting in their homes to die. A decade later, Yates’ research proves that user fees are not only inequitable, but they are also ineffective at raising revenue for the health sector.  

	Lines outside a clinic the first day user fees were eliminated for mothers and children in Sierra Leone.

In 2008—facing the highest rate of infant mortality at 123 per 1,000 live births and one of the highest rates of maternal mortality in the world—the government of Sierra Leone asked Ministry of Health official Dr. Kargbo to investigate the impact of user fees in the country. 

An overwhelming 88 percent of survey respondents determined cost to be the biggest obstacle to accessing health care, followed by distance/lack of transportation (six percent), lack of staff (two percent), lack of drugs (two percent), and inadequate or no health facility (one percent). On April 27, 2010, Sierra Leone took decisive action and eliminated user fees for children and for pregnant and lactating women. Clinic-based births increased more than five-fold, raising the bar on what is possible for the mothers of Sierra Leone.

Evidence emerging from Sierra Leone and other African countries demonstrates that with support from donor agencies, governments can improve health outcomes for the poor by abolishing user fees. But targeted financing is necessary. These concurrent reforms, such as increasing health workers’ salaries and benefits, procuring additional medicines and supplies, and increasing financial flows to front line services, are requisite to ensuring effective and equitable health services.  

Today the international community increasingly recognizes that user fees discriminate against the poor. But reform has been slow. It is time for all international donors to commit to supporting poor country governments which choose to remove user fees from public health facilities.  

Learn more about PIH's advocacy work.