Poverty and user fees for public health care in low-income countries; lessons from Uganda and Cambodia [viewpoint]

Public health systems in most low-income countries are unfair to poor people. Clearly preventive and curative public health-care services, especially hospital services, are accessed by poor people less frequently than by those who are better off.1,2 This injustice is now high on the international agenda. A solution for this issue has some global dimensions, such as the need for a large transfer of resources from high-income to low-income countries.3 Yet, in terms of the best use of these supplementary resources, defi nite solutions should be developed in every country. National policy makers have strategic choices to make in their eff orts to reach poor people.4 One option that policy makers might consider is the removal of the fees charged to users by public health facilities. A key strategy in the 1980s was user fees,5 whic

Removing user fees in the health sector: a review of policy processes in six sub-Saharan African countries.

In recent years, governments of several low-income countries have taken decisive action by removing fully or partially user fees in the health sector. In this study, we review recent reforms in six sub-Saharan African countries: Burkina Faso, Burundi, Ghana, Liberia, Senegal and Uganda. The review describes the processes and strategies through which user fee removal reforms have been implemented and tries to assess them by referring to a good practice hypotheses framework. The analysis shows that African leaders are willing to take strong action to remove financial barriers met by vulnerable groups, especially pregnant women and children. However, due to a lack of consultation and the often unexpected timing of the decision taken by the political authorities, there was insufficient preparation for user fee removal in several countries. This lack of preparation resulted in poor design of the reform and weaknesses in the processes of policy formulation and implementation. Our assessment is that there is now a window of opportunity in many African countries for policy action to address barriers to accessing health care. Mobilizing sufficient financial resources and obtaining long-term commitment are obviously crucial requirements, but design details, the formulation process and implementation plan also need careful thought. We contend that national policy-makers and international agencies could better collaborate in this respect