Removing user fees in Africa: more than a technical challenge

The introduction of user fees (formal payments at the time of seeking care at public health facilities) to finance healthcare in Low- and Middle-Income Countries (LMICs) in the 1980s has been, and remains, a controversial topic. User fees represent a key financial barrier to accessing care, particularly for poor people who may be further impoverished as a result of seeking care. The economic arguments in favour of user fees have been contested. Yet, despite the mounting evidence against them, user fees persist across most African countries. This thesis seeks to answer the following research questions: Why have user fees persisted as a health financing mechanism in face of evidence that they present a financial barrier to access? What has constrained efforts to remove user fees, and particularly, what are the relative contributions of technical factors versus complex political interests that may have shaped these health systems policies? The thesis takes the form of five papers and uses a combination of literature reviews, qualitative and quantitative methods. The first paper, Witter S, Anderson I, Annear P, Awosusi A, Bhandari N, Brikci N , Blandine B, Chanturidze T , Gilbert K , Jensen C, Lievens T , McPake B , Raichowdhury S and Jones A (2019), starts with a scoping review on the content of learning across health systems, a scoping review of institutions and platforms that facilitate learning, and a review of international health policy transfer studies. It includes the results of key informant interviews (KIIs). The second, McPake B, Brikci N, Cometto G, Schmidt A and Araujo A (2011), reviews studies on user fees experiences in developing countries, and on Uganda specifically. The third, Witter S, Brikci N, Harris T et al (2018), reviews regional experiences in removing user fees and Sierra Leone specific efforts in strengthening its health system to remove user fees. It also analyses the results of KIIs and Focus Group Discussions (FGDs), as well as the fiscal space for free health care in Sierra Leone. The fourth, Mathauer I, Koch K, Zita S, Murray A, Traore M, Bitho N and Brikci N (2019), presents a review of innovative taxes in Low- and Middle-Income Countries (LMICs), findings from a multistakeholder consultation, and a feasibility analysis of various taxes. The last, Brikci N. (2023), provides a systematic literature review of innovative domestic financing mechanisms for health. The research contributes to the literature on health financing and removal of user fees in three interrelated ways. First, it shows that the identification of the removal of user fees as a national priority was the result of a complex interaction of primarily locally determined factors and the meeting of technical solutions with the interest of actors and institutions through a political window of opportunity. The absence of this window of opportunity may explain why user fees persist. Secondly, the work highlights the fundamental importance of integrating technical aspects and those that reflect the wider context affecting health systems. Indeed, the formulation and implementation of user fee removal requires (1) a systematic, step-by-step strengthening of each of the health systems pillars and (2) a careful consideration of the interests of actors impacted by the reform, of the readiness of formal and informal institutions to implement and accept the reform, and of the ideas and ideologies that the reform would challenge. Thirdly, the work discusses the alternatives to user fees, specifically the role of domestic ‘innovative’ financing mechanisms to replace them. It shows that these financing mechanisms may not offer much additional resource for health, although they represent a useful avenue for dialogue between Ministries of Health (MoH) and Ministries of Finance (MoF)