news analysis advocacy
AfricaFocus Bookshop
New Gift CDs
China & Africa
tips on searching

Search AfricaFocus and 8 Partner Sites



Visit the AfricaFocus
Country Pages

Burkina Faso
Cape Verde
Central Afr. Rep.
Congo (Brazzaville)
Congo (Kinshasa)
Cte d'Ivoire
Equatorial Guinea
São Tomé
Sierra Leone
South Africa
South Sudan
Western Sahara

Get AfricaFocus Bulletin by e-mail!         More on politics & human rights | economy & development | peace & security | health

Print this page

Africa: User Fees

AfricaFocus Bulletin
Apr 2, 2006 (060402)
(Reposted from sources cited below)

Editor's Note

"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 poor

Oxfam Press Release - 31 March 2006

Oxfam International

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 120 (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 Malawi.

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

Mark Pearson

September 2004

DFID Health Resource Centre

Executive Summary

[Excerpt only. Full text of executive summary and report available at]

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 to access.

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 getting worse.

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 revenue.

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 address poverty.

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 Declaration?
  • 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 sector?

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: 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; 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. 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 poverty.

AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

AfricaFocus Bulletin can be reached at Please write to this address to subscribe or unsubscribe to the bulletin, or to suggest material for inclusion. For more information about reposted material, please contact directly the original source mentioned. For a full archive and other resources, see

Read more on |Africa Health||Africa Economy & Development|

URL for this file: