Is the jury still out on the impact of user fees in Africa? A review of the evidence from selected countries on user fees and determinants of health service utilisation

Abstract

The study objective was to understand the impact of user fees on access to health services in countries in Africa, using evidence from selected countries (Tanzania, Mozambique, Mali, Benin, Chad, Rwanda and Madagascar). More specifically, the aim was to present evidence about the extent to which user fees act as a deterrent to the use of health services, as well as other barriers to care, with focus on poor and vulnerable groups. This was a desk study, using 84 published and unpublished studies. Several important conclusions are observable from the studies reviewed. First, if there are no other changes introduced, the application of user fees reduces utilisation, particularly of poorer households. Second, with quality improvements of the price effect on utilisation may be offset, and in some settings increases in utilisation have been found following introduction of user fees. Third, there are other important determinants of the use of modern health services which should be considered, such as distance to facility and time access, disease type and severity, education level, cultural factors and the availability and price of other "traditional" forms of health care. Unofficial charging has also been found to be common, representing a further barrier to modern health services. In conclusion, due to the variety of experiences with user fees there is no standard policy that can be applied throughout Africa. Instead the willingness and capacity to pay, solidarity, access to alternative health care providers and financing mechanisms, potential for improvements to health services, and feasibility of user feee exemptions for disadvantaged groups, shouls be taken into consideration before changing user fee policy.
East African Medical Journal Vol.81(4) (Supplement) April 2004: S45-S60