Waivers and Exemptions of User Fees for Health Services: The Debate Shall Continue

By Gelila Getaneh

Governments have the responsibility to provide health care to their citizens and finance their health systems. Yet, we know that some have had the ability to invest more than others. Low and middle-income economies experiencing a large population boom have been forced to come up with innovative fundraising mechanisms to fund their health systems – and most countries implemented informal and formal user fees. The World Bank argues that this can be a powerful tool for financing, as it allows allocating resources according to the need of the health care system. Moreover, countries have the obligation to offer a waiver or an exemption to people that can’t afford to pay the fees; so it argued this would also eliminate the access issue.

However, current evidence from countries like, Tanzania suggests that waivers or exemptions have not increased equity in access and in financing of health services. For example, people who had these “privileges” were not visiting health centers more than other people in their community. In addition, waivers and exemptions did not address the issue of demand; so there were poor people with exemptions, but did not have the opportunity to receive health services. Most of these countries don’t have the means to differentiate between the poor from the non-poor; so implementing these policies has been difficult. Also, opponents point out that the quality of the health care service in these countries needs to improve before implementing these types of tools.

On the other hand, supporters of waivers and exemptions advocate for the strengthening of these type protection mechanisms. They argue that private hospitals or clinics do not have the incentive to waive fees for the poor people; so it is important for the government to make this decision. After comparing the waiver systems between Tanzania, Thailand and Cambodia, researchers said these programs could work, as long as, they are implemented correctly. For the most part, the protection mechanisms in, Thailand and Cambodia are working properly; so it might be easy for other countries to adopt the same model.

Countries have tried different approaches to make access health care fairer. Since, the World Bank introduced the idea of user fees, many developing countries have tried to implement the program, but it is very clear that some countries are definitely doing a better job than others. So, while the debate on waiver and exemption of user fees continues, researchers and countries must come together and see how they can strengthen this model in countries that have been “unsuccessful”? Of course, at the end governments are the only ones that should decide their health financing policy.


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