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Africa: User Fees
Apr 2, 2006 (060402)
(Reposted from sources cited below)
"The government of Zambia today (1 April) introduced free health
care for people living in rural areas, scrapping fees which for
years had made health care inaccessible for millions. The move was
made possible using money from the debt cancellation and aid
increases agreed at the G8 in Gleneagles last July, when Zambia
received $4 billion of debt relief; money it is now investing in
health and education." - Oxfam International
This step represents a growing recognition by aid agencies as well
as analysts that health and education should be considered
productive collective investments rather than commodities subject
to short-term cost recovery. This AfricaFocus Bulletin includes the
press release from Oxfam International on the policy change in
Zambia, and excerpts from a 2004 background paper on user fees from
the UK Department for International Development (DFID). The DFID
paper notes that "the case for removing official user fees for
primary health services is strong," but cautions that this measure
should not be regarded as a panacea or divert the attention from
the broader need for adequate investment in health.
Additional background on the user fees debate can be found in
another DFID briefing paper:
Charting the path to the World Bank's "No blanket policy on user
fees": A look over the past 25 years at the shifting support for
user fees in health and education, and reflections on the future
Guy Hutton, May 2004
Another AfricaFocus Bulletin sent out today consists of excerpts
from a report on the related issue of using social transfers to
improve human development.
Translated into simpler English, these reports on user fees and
social transfers seem to show that the most immediate ways to help
the poor are common-sense remedies: stop making them pay for
essential services and give them cash.
++++++++++++++++++++++end editor's note+++++++++++++++++++++++
Zambia uses G8 debt cancellation to make health care free for the
Oxfam Press Release - 31 March 2006
The government of Zambia today (1 April) introduced free health
care for people living in rural areas, scrapping fees which for
years had made health care inaccessible for millions.
The move was made possible using money from the debt cancellation
and aid increases agreed at the G8 in Gleneagles last July, when
Zambia received $4 billion of debt relief; money it is now
investing in health and education.
65 per cent of Zambia's citizens live on less than a dollar a day.
Until today the average trip to a clinic would have cost more than
double that amount, the equivalent of a UK worker having to œ120
(US$200) just to visit a clinic.
"This is one of the first concrete examples of how the G8 deal last
year has made a real difference to peoples' lives," said Barbara
Stocking, Director of Oxfam. "People often bemoan the lack of good
news coming out of Africa - well here's an example of real
progress. It shows what can happen when people both in the rich
world and the developing world push their leaders to deliver. Those
who backed the Make Poverty History campaign last year should be
proud of this achievement."
User fees were introduced in Zambia under IMF and World Bank
pressure in the early 1990s. Young girls in rural areas were the
main victims of the policy as their families were rarely willing or
able to pay for their treatment.
Now that user fees for health have been scrapped, experience from
other countries shows that there will be a surge of patients
accessing health clinics across the country, many of these people
would not have been able to afford care previously. In Uganda most
clinics saw a doubling in their patient numbers.
According to Oxfam, Zambia's next challenge will be their chronic
shortage of health workers. There is currently only one doctor per
14,000 people in Zambia (compared to one doctor per 600 people in
the UK) and the numbers of nurses in the country needs to be
doubled. Health workers are currently paid a pittance in the public
sector and have to work in appalling conditions.
"We commend the government for removing user fees in rural areas
and urge them to do the same in urban areas. This is the first step
towards addressing the health crisis in Zambia. More money is now
urgently needed for medicines and to improve the working conditions
of doctors and nurses," said Henry Malumo, National Coordinator for
the Global Call to Action against Poverty in Zambia.
To ensure that the scrapping of fees results in high quality health
care Oxfam is calling on donors to provide Zambia with support for
the training and recruitment of health care workers, such as that
Britain's Department for International Development is providing in
The IMF also needs to ensure that its loan conditions do not
restrict the employment of extra health care workers.
"Today's announcement will make a real difference to millions of
poor people. On the ground it will mean thousands of people get
treatment for the first time in their lives. Zambia will need
continued support to recruit new staff but this is a massive leap
in the right direction. We now need other African countries to
follow suit," said Barbara Stocking, director of Oxfam.
In a recent survey of 30 African countries only 3 did not have user
fees for heath care. Contact
For more information, a VNR (including health pictures from Zambia)
or for interviews please contact Nicky Wimble on + 44 1865 47 2498
or +44 7876 476 402 Nicky Wimble, Oxfam Press Officer +44
1865-472-193 office +44 7876-476-402 (work mobile) +44 7745-783-478
The case for abolition of user fees for primary health services
DFID Health Resource Centre
[Excerpt only. Full text of executive summary and report available
i. Improving access to basic health care can help accelerate
progress towards the MDGs. Cost is usually the major obstacle
preventing the poor from accessing basic health care. Improving the
affordability of essential health care services requires measures
aimed at reducing all costs - whether they are official fees,
informal out of pocket payments or indirect costs such as
transport. User fees contribute to the financial burden although in
many countries they are not the most significant financial barrier
In most countries a high proportion of basic services are provided
by the private sector at market prices and although the poor are
more likely than the better off to use lower cost services provided
by the public sector they still make heavy use of the private
sector This comes at a cost with such health expenditures driving
many into poverty. Overall public funding for health is extremely
low in most of DFID priority countries; it is also poorly targeted.
This partly explains the fact that the better off have much better
access to services and enjoy better health outcomes. In around a
quarter of the countries the problem is not the lack of progress
towards the MDGs it is that health indicators are actually
ii. The case for removing official user fees for primary health
services is strong. They raise little money and rarely meet their
stated efficiency and equity goals. They are often associated with
reduced utilisation of services especially by the poor and
vulnerable (resulting in greater reliance on often inappropriate
forms of self treatment), a failure to complete treatment
(resulting in problems of drug resistance) and delays in seeking
treatment (resulting in worse health outcomes).
Although, user fees rarely present the most important financial
barrier they are the one most amenable to policy action. As the
recent experience in Uganda shows that with sufficient political
commitment the elimination of fees can play a catalytic effect in
forcing Government to confront other issues such as financial
management problems and drug supply and procurement which pose
further barriers to progress. In some countries abolishing user
fees is seen as the only viable exemption policy. Nonetheless they
tend to be kept in place by powerful vested interests e.g. by
health workers whose rewards are directly affected by user fee
iii. Removing fees needs to be accompanied by a range of actions
including increased and well directed funding (above and beyond the
loss of fee revenue) if it is to lead to sustained improvements in
access for the poor. It would require additional funding to allow
quality to be maintained in the face of increased demand and to
increase health worker pay to increase productivity as well as an
effective communications strategy to make the case to those likely
to be affected by the changes. If Governments abolish fees and do
absolutely nothing else (and ignore the caveats and requirements
for complementary reforms) it is highly unlikely to lead to
sustained improvements in the long term as experiences in Zimbabwe,
South Africa and Kenya suggest. It could even make things worse.
iv. Clearly removing user fees is not a panacea. In many
circumstances, though, it could reduce the currently unaffordable
financial burden faced by poor people. Where user fees are
undermining equity or efficiency goals DFID should be willing to
support Governments wishing to implement such a policy as part of
a balanced and well considered programme to improve access and
v. The case for having a blanket DFID policy on user fees for basic
health is highly questionable. Firstly, user fees can, in some
circumstances, improve access. User fees have been associated with
increased utilisation of services in some settings. ... Secondly
even if user fee abolition does make sense it can be argued that it
is actually a relatively minor issue in terms of the overall
poverty reduction agenda (see para viii). Indeed in a number of
countries advisers felt that abolishing user fees would make no
difference. Thus, whilst it may make some sense to support user fee
abolition as "a" DFID policy it does not necessarily warrant being
the" next big DFID policy". ...
vi. The issue is clearly context specific depending heavily on
where Government is coming from and on its capacity and commitment
to implementing such reforms. ...
vii. Are there rough rules of thumb to suggest where user fee
abolition might work? Some suggested that abolition may make sense
in settings where spending is at reasonable levels, with a sensible
balance between prevention and cure, primary, secondary and
tertiary care with prospects for future increases, where systems
are reasonably robust, where there is a community/civil society
voice and there is strong political commitment. This may be true in
Uganda, South Africa and Tanzania, possibly in Ghana and Zambia,
probably not in Kenya and almost certainly not in Nigeria and
Ethiopia and countries emerging from crisis
viii. The case for promoting a specific policy advocating for the
abolition of user fees for basic health care would therefore seems
to be as much a tactical one as a technical one. ...
ix. Do we completely miss the point by focusing on user fees for
basic health care? Firstly, it is the fees associated with hospital
care and chronic illness and not at primary care levels which cause
the greatest financial problems. Secondly, other financial
constraints such as indirect costs and informal user charges are
often far more important. Thirdly, there are also significant non
financial barriers to accessing health care. Fourth, and perhaps
most importantly, the private sector delivers most primary health
in most countries and even poorer groups are more likely to use the
private than public sector. Lastly, it can be argued that user fees
have typically been seen as residual funding or as gap filling. As
such they are a symptom of an underlying problem the failure to
allocate adequate resources to primary health. This would suggest
DFID focus on the causes (lack of budgetary support for primary
health care) rather than the symptom (the need for user fees).
x. An alternative approach would be to put forward a broader
message that DFID policy is to make essential services more
affordable to poor people. This would clearly highlight the
underlying concern but be more open to different country led
approaches to addressing the issue. Within such a policy it would
still be possible to say that, in general, DFID does not support
user fees for primary care.
xi. In considering a line to take DFID needs to be clear on:
- what is meant by essential or basic services? A narrow definition
could be taken to mean services with significant public health
benefits (externalities) and preventive services provided at
primary care level and exclude curative services provided at
primary care level where the benefits accrue only to the
individual. A broader definition might include all services
provided at primary levels. An even broader definition might
include selected additional services, such as essential obstetric
care, which can only be provided at higher levels but which are
essential for the achieving the MDGs. It also needs to be
recognised that much primary care is delivered at hospital level
- what is actually meant by user fees and where we draw the line?
- if we are talking about primary care do we also consider water
and sanitation, nutrition and education as set out in the Alma Ata
- how do we deal with current issues of under funding in the public
sector? We can abolish fees for drugs but if they are not available
in health facilities people will still have to go to purchase from
pharmacies? So are we talking about advocating for the abolition of
the Bamako initiative and fully funding drug requirements for PHC?
What about social marketing?
- are we just talking about fees for services provided in the
public sector? What about services provided by NGO or mission
facilities on behalf of Government as is the case in a number of
DFID PSA countries? Should people be disadvantaged just because
they live next to an NGO rather than a Government facility? Taking
this argument further what about the vast majority of primary
health services which are typically delivered in the private
xii. Estimates of the cost implications are crude and highly
dependant upon how the issue is defined and likely take up at the
country level. ...
xiii. This might be enough to deliver the current inadequate range
of services. Funding to provide a decent package of essential
services free at the point of delivery would cost much more.
Increasing spending on essential drugs could cost up to $4bn and
increasing public spending to levels required to deliver a
comprehensive package of essential services anything from $17bn
(WDR 1993) to $88bn per year (CMH 2001). Costs of making NGO
services free would also be significant in a number of countries.
More work would be required at country level to estimate actual
needs; more needs to be done at country level to track expenditure
levels and allocations (through NHA type exercises).
xiv. Would it make sense for DFID to link the issue with direct
financing? Countries would presumably expect it but would such an
earmarked and "projectised" approach be consistent with broader
moves towards promoting Government leadership and the use of
unearmarked budget support? Again views varied from it being
"absurd" to link the policy change with direct funding to a more
pragmatic view that it would not happen unless more resources were
on offer ...
xv. The pros and cons of a range of policy stances are spelt out in
the paper. A possible alternative line to one focused solely on
user fees would be to take a broader approach which, although less
succinct, may have more global relevance: ú DFID supports countries'
efforts to ensure universal access to essential/basic health
services that deal with the major causes of ill health, disability
and death; ú DFID recognises that reducing the financial barriers
which currently prevent access could make a major contribution to
this goal and will support countries in their efforts to this end.
ú DFID believes that in low income countries such services should
be provided free of charge at the point of use where current
approaches compromise equity goals and where the necessary
complementary actions are adopted and it forms part of a balanced
and well considered programme to improve access and address
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