Scrapping user fees "just the first step"

Donor-backed user fees for health services were supposed to decentralise primary healthcare and provide revenue for essential drugs: instead, advocacy groups charge, they have ended up killing the poor in the developing world.

For the vulnerable, even nominal fees can mean a denial of access to basic healthcare – especially among women and children. According to the online research guide Eldis, user fees “appear to have raised less revenue than expected; have acted as a disincentive for both poor and non-poor people to use health services; and have not led to the degree of community participation envisaged”.

Anti-user fee campaigners have now won powerful international backing from, among others, British Prime Minister Gordon Brown. Six countries - Malawi, Liberia, Sierra Leone, Ghana, Nepal and Burundi – are to receive US$5.3 billion in financing raised by the high level taskforce on International Innovative Finance for Health Systems, to help them extend free healthcare to women and children.

But doing away with user fees alone is no panacea to improving medical access for the poor. “Focusing on user fees may do little to improve access as there are usually other, greater financial barriers such as purchasing drugs, unofficial fees, and transport,” Eldis noted.

In a 14 September policy paper – Your Money or Your Life – a group of NGOs and health organizations stated: “The need to make healthcare free and expand access in these and other countries is beyond question, but to do so successfully requires high-level political commitment and sustained additional financial and technical support.”

Donor funding is notoriously unreliable; governments may well eventually have to turn to taxation to cover those costs – or a hybrid mix of free care for the poorest, and national insurance schemes for those who can afford to pay modest premiums. Meanwhile, most African governments are still well short of fulfilling their commitment made in 2001 at Abuja, Nigeria, to allocate 15 percent of their budgets to health.

“Ultimately the decision to abolish or keep fees has to be made as part of broader health sector financing policy,” Eldis concludes.

IRIN looks at the state of healthcare in three of the countries that have won funding:

Photo: WHO
Government expenditure on health

Sierra Leone

The government plans to make healthcare free for pregnant and lactating women and under-fives by January 2010. But in a country with only about 170 doctors for more than five million people, minimal medical supplies and a health infrastructure still crawling back from 11 years of civil war, an enormous job lies ahead to ensure the free service will be a quality service.

“We must prepare health facilities for the four- to 10-fold increase we can expect from abolishing health fees,” Samuel Kargbo, the Health Ministry's director of reproductive and child health, told IRIN. “When we eliminate health user fees we must have sufficient equipment, manpower and medicines. Otherwise we negate everything we are trying to do.”

The government has made pronouncements of free care in the past but it was never backed up with the necessary planning and infrastructure.

Now a working group – representatives of the Health Ministry, donors, development organisations and NGOs – is studying how to implement free care in a sustainable way. Doctors from Nigeria and Cuba are due in Sierra Leone in the coming weeks, but in the longer term Sierra Leone needs to produce more doctors and retain them, Kargbo said.

“There are many hurdles to overcome,” noted Jan van ‘t Land, head of mission with Médecins Sans Frontières (MSF) in Sierra Leone. “Logistics and human resources are two of the biggest weaknesses of [this country’s] health system.” MSF is a member of the working group.

“The main question is who will pay in the end; it will cost a lot of money. The political will is there. I am hoping the government’s final policy on providing free care for pregnant women and under-five children will not be just another document,” said Van ‘t Land.

Sierra Leone’s free-care policy will be part of a two-pronged approach, with a national health insurance scheme to be introduced in the coming years, according to Health Ministry officials.


In 2006, the government introduced free healthcare for maternal deliveries and children under five.

“Before the free medical care measure, 20.4 percent of women delivered at hospital. In 2007, 41 percent of women went to hospital, while in 2008 the number reached 47 percent. We expect to reach 51 percent this year,” Sostène Hicuburundi, in charge of health funding in the Ministry of Public Health, told IRIN. There has also been a significant rise in treatment of under-fives.

But there have been problems with implementation, with the health system unprepared for the rise in demand.

“Our work has doubled, even tripled. Before the measure we did from 35 to 40 caesarean sections per month. We now carry out about 65,” said Spes Ntaconayigize, head nurse of the gynaecology unit at Prince Regent Charles Hospital in the capital, Bujumbura.

A lack of equipment and staff shortages have taken their toll. "A woman can spend 24 hours on a stretcher after delivery for lack of beds. This is painful for us as the patient sometimes does not understand why she remains there. The lack of material adds to the stress on us," said Ntaconayigize.

According to Your Money or Your Life, “The performance of the existing free healthcare policy is compromised by inefficient reimbursement procedures for health facilities and insufficient support from aid agencies.”

Read more 
 Great leap forward on free healthcare
 Government weighs “hybrid” health care plan
 Going into debt for health
 Emergency wheelbarrows replace missing doctors


Free is not always free. People living with HIV in Mozambique have access to free antiretroviral (ARV) treatment, but they must pay hospital user fees and for medicines to treat common HIV-related infections.

Hospitals charge patients an administrative fee of only 10 Meticais (US$0.37), but according to Alain Kassa, MSF head of mission, even that small amount is a barrier for many people, especially when combined with the cost of transport from distant rural areas.

Drugs to treat opportunistic infections, which are supposed to be free, are also not always available.

"This is commonplace: not to find prophylactics, antibiotics or Paracetamol [pain medication] in those public pharmacies," said Cesar Mufanequisso, coordinator of a local NGO, Movement for Access to Treatment in Mozambique (MATRAM). "People living with HIV get their ARVs free, but other medicines are usually out of stock and they have to buy them."

Those who cannot afford to go to hospital or buy medicines from private pharmacies “often opt to see a traditional healer who will allow them to pay at a later stage”, said Nacima Figia, HIV coordinator for the international anti-poverty NGO, ActionAid.