User fee removal in the health sector in low-income countries: lessons from recent national initiatives


Edited by Bruno Meessen, Lucy Gilson and Abdelmajid Tibouti

Health Policy and Planning – Volume 26, Supplement 2 – November 2011

This supplement, sponsored by Unicef, focuses on the challenges related to the design and implementation of user fee removal policies in low-income countries.

“User fees have triggered impassioned discussions in international health over the last two decades. Promoted by a number of international organizations since the late 1980s as a strategy to finance struggling public health facilities in many low-income countries, recent years have seen growing criticism of the impact of fees on access to health services, particularly for the poorest groups…..

In mid-2008, UNICEF approached a group of researchers with the request to document recent experience with user fee removal. While aid actors in the North were still arguing fiercely about the pros and cons of user fees, a growing number of countries had already decided to remove user fees, at least for some priority services…. A consensus was easily reached between UNICEF and the research team led by the Institute of Tropical Medicine, Antwerp: the multi-country review would not (again) focus on evidence against or in favour of user fees, but would instead try to document how countries formulated and implemented user fee removal.

This focus was seen as valuable because it could generate practical lessons for other countries interested in such a step…. the research team judged that the main question of the multi-country review—the challenges related to design and implementation of user fee removal policies—deserved more visibility than just another report….

Our objectives for this supplement were multiple. From the start we decided we would welcome contributions from different regions and fields of expertise, as the supplement had to be useful for researchers, but also for programme officers and policy makers directly involved in health care financing policies in low-income countries. We acknowledged that contributors would adopt different types of methodological approaches to address different questions. We were also keen to get contributions from the different ‘corners’ of the user fee debate. Experts familiar with the controversy can see for themselves that this objective has been achieved; a glance at the list of contributors to this supplement suffices….”

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