Moving Forward From User Fees to Universal Health Care in Africa

There has been a recent trend in Global Public Health toward the reversal of implementing user fees to access healthcare in developing countries. This trend has been seen mostly in Sub-Saharan and Western Africa. In 1987, an influential report issued by the World Bank highlighted and encouraged various governments to adopt user fees for their citizens to access various forms of care. This report explained that the implementation of user fees was not only effective and efficient, but also equitable. After this report, many countries throughout Africa adopted this policy. It took no more than ten years until studies were released that concluded that not only did user fees decrease primary health care utilization, but increased the already large disparity that existed between the poorest citizen and the middle class. It became apparent that while user fees did raise revenue that could be devoted toward health care spending by the respective governments, it was a significantly smaller proportion than expected. The World Bank assumed that 15-20% of health care spending could be raised by adopting user fees but in practice this figure was more like only 5-6%. This was not the only falsity that came to light from the implementation of user fees; the poor began to suffer from a higher burden of disease because they could not access the health care and were also becoming more “impoverished by the effects of high catastrophic health expenditures” (Yates 1). The only solution to these growing problems of inequality was to reverse the user fee policies. Many countries throughout Africa began to slowly revert back to their previous healthcare infrastructure systems, but making some very wise alterations learned from their negative experiences with user fees. Instead of implementing user fees for patients, many African countries have begun the process of examining the possibility of universal health care coverage for all citizens. While this seems like the most obvious solution to the problem of access for patients, many problems exist with securing adequate financing. Valuable lessons can be learned from the semi-universal healthcare system that was recently implemented in Sierra Leone. To address one of the most common national health issues, child and maternal mortality, Sierra Leone adopted universal coverage for expecting and lactating mothers, in addition to their children under the age of 5. You may ask how could such a poor and war-torn country adapt such a radical policy? The answer lies in governmental fervor for the issue and proper coordination between the various departments and organizations responsible for national healthcare. While it remains to be unseen whether or not this universal healthcare coverage has reduced child and maternal mortality, it has certainly significantly increased healthcare usage. Almost immediately after the implementation of this policy healthcare utilization rose 60%! Very valuable lessons can be learned from this specific example in Sierra Leone. Rather than implementing user fees for services, a slow transition to partial universal coverage for the most vulnerable populations of a country is the most important first step. In my opinion, as long as the service is free at the point of service, does not decrease healthcare utilization, has proper governmental support including financing, it is an excellent step in the right direction toward eventually securing better health for all.

“Universal Health Care and the Removal of User Fees.” By Rob Yates. The Lancet, 2009 373: 2078-81

“How did Sierra Leone provide free health care?” By John Donnelly. The Lancet, Volume 377, 1393-1396.


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