Abolition of user fees: do we (really) know enough?

By Valéry Ridde and Emilie Robert, University of Montreal

“I think the bank was ideological”, in an interview with The Guardian last month the President of the World Bank surprised everyone by acknowledging that his institution had for years promoted user fees on the basis of an ideology.
Remember, this is the same organisation that published a report in 1987 asserting that “charg[ing] users of government health facilities [will] increase access for the poor.” In 2014, one of the authors of that report backtracked on his statements, declaring that user fees are “a practice that effectively burdens sick and needy people, a small and vulnerable segment of the population.”  These days there appears to be a general consensus emerging against user fees and supporting their abolition. The United Nations agencies, the European Union (2009) and the African Union (2010) have been calling for it. The World Bank now finally appears to be following in their footsteps.

The progression of these ideas, even if they are not yet fully shared by everyone on the ground, is due in large part (though not exclusively) to the accumulation of scientific evidence. The unjust and unnecessary nature of user fees has been clearly proven. For at least 10 years now, we have also been compiling a body of evidence on the effects of user fees abolition on the use of services. Several syntheses have been published in Health Policy and Planning and elsewhere.  The recent article by McKinnon and colleagues fits within this evidence gathering process. This study is particularly interesting because it is one of very few studies to use population data. These data confirm the positive impacts of user fees abolition on use of services and reductions in neonatal mortality, which is consistent with conclusions coming out of studies in Niger, Burkina Faso and Thailand regarding other health outcomes.

Despite these lessons, McKinnon’s study does not really capture the issues involved in the complexity of such an intervention, and yet these are immense. Of course, that was not the authors’ objective. It should, however, become a priority for the scientific community. While there is a growing body of quantitative knowledge on health services use, there are still far too few mixed methods interdisciplinary studies, which are essential to understand these complex interventions in their context, that is, in real-life conditions. Our most recent survey on this topic revealed the desperate lack of any systemic approach. Yet the task is not impossible, as shown by research teams in Burkina Faso, Mali, Niger, and Zambia, and by others who are expected to report soon on their work along these lines in Benin and Morocco.

Now that the effectiveness of user fees abolition has been demonstrated, we need to support decision-makers by supplying them with knowledge on the appropriate measures to take to fund abolition, implement it, improve its equity, adapt it to local contexts and healthcare systems, understand the roles of social actors, etc. While some studies on these subjects are beginning to emerge, they are still in very short supply. Are researchers and research funding agencies not interested in these issues? How do we explain, for example, the recent call put out by the Alliance for Health Policy and Systems Research for a better understanding of the implementation of results-based financing, which is very relevant, whereas this has never been done for user fees abolition interventions? Scientific choice, or ideological?

Producing evidence on the complexity of user fees abolition interventions is crucial to support the implementation of universal coverage, as called for in March 2014 by WHO and the African Union and which all international actors hope to see in place by 2030. For this to happen, it would be good, and necessary, to deploy a new generation of studies that focus on people and explore the complexity of these interventions. Calling all young researchers, emerging voices and other people-centred scientists! Could we see some potential solutions at the Third Global Symposium on Health Systems Research?

Acknowledgements : Thanks to Donna Riley for translation and editing support.


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