Applied Health Economics and Health Policy

, Volume 5, Issue 3, pp 137–153 | Cite as

To Retain or Remove User Fees?

Reflections on the Current Debate in Low- and Middle-Income Countries
  • Chris D. James
  • Kara Hanson
  • Barbara McPake
  • Dina Balabanova
  • Davidson Gwatkin
  • Ian Hopwood
  • Christina Kirunga
  • Rudolph Knippenberg
  • Bruno Meessen
  • Saul S. Morris
  • Alexander Preker
  • Yves Souteyr
  • Abdelmajid TiboutiEmail author
  • Pascal Villeneuve
  • Ke Xu
Review Article


Many low- and middle-income countries continue to search for better ways of financing their health systems. Common to many of these systems are problems of inadequate resource mobilisation, as well as inefficient and inequitable use of existing resources. The poor and other vulnerable groups who need healthcare the most are also the most affected by these shortcomings. In particular, these groups have a high reliance on user fees and other out-of-pocket expenditures on health which are both impoverishing and provide a financial barrier to care.

It is within this context, and in light of recent policy initiatives on user fee removal, that a debate on the role of user fees in health financing systems has recently returned. This paper provides some reflections on the recent user fees debate, drawing from the evidence presented and subsequent discussions at a recent UNICEF consultation on user fees in the health sector, and relates the debate to the wider issue of access to adequate healthcare. It is argued that, from the wealth of evidence on user fees and other health system reforms, a broad consensus is emerging. First, user fees are an important barrier to accessing health services, especially for poor people. They also negatively impact on adherence to long-term expensive treatments. However, this is offset to some extent by potentially positive impacts on quality. Secondly, user fees are not the only barrier that the poor face. As well as other cost barriers, a number of quality, information and cultural barriers must also be overcome before the poor can access adequate health services. Thirdly, initial evidence on fee abolition in Uganda suggests that this policy has improved access to outpatient services for the poor. For this to be sustainable and effective in reaching the poor, fee removal needs to be part of a broader package of reforms that includes increased budgets to offset lost fee revenue (as was the case in Uganda). Fourthly, implementation matters: if fees are to be abolished, this needs clear communication with a broad stakeholder buy-in, careful monitoring to ensure that official fees are not replaced by informal fees, and appropriate management of the alternative financing mechanisms that are replacing user fees. Fifthly, context is crucial. For instance, immediate fee removal in Cambodia would be inappropriate, given that fees replaced irregular and often high informal fees. In this context, equity funds and eventual expansion of health insurance are perhaps more viable policy options. Conversely, in countries where user fees have had significant adverse effects on access and generated only limited benefits, fee abolition is probably a more attractive policy option.

Removing user fees has the potential to improve access to health services, especially for the poor, but it is not appropriate in all contexts. Analysis should move on from broad evaluations of user fees towards exploring how best to dismantle the multiple barriers to access in specific contexts.


Equity Fund Informal Payment Conditional Cash Transfer Catastrophic Health Expenditure Cost Barrier 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



This paper reflects its authors’ personal views and does not necessarily represent the view of their organisations or institutes.

No funding has been provided to the authors of this paper by UNICEF. The role of UNICEF was limited to convening the expert consultation on user fees in the health sector. The decision to co-author a paper summarising the discussions and conclusions of the expert consultation was a joint decision by all authors.

No conflict of interest is discernible for any of the authors of the paper.

All authors have made significant contributions to the paper.

We would also like to acknowledge the insightful comments from an anonymous reviewer.


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Copyright information

© Adis Data Information BV 2006

Authors and Affiliations

  • Chris D. James
    • 1
  • Kara Hanson
    • 1
  • Barbara McPake
    • 2
  • Dina Balabanova
    • 1
  • Davidson Gwatkin
    • 3
  • Ian Hopwood
    • 4
  • Christina Kirunga
    • 5
  • Rudolph Knippenberg
    • 4
  • Bruno Meessen
    • 6
  • Saul S. Morris
    • 1
  • Alexander Preker
    • 7
  • Yves Souteyr
    • 8
  • Abdelmajid Tibouti
    • 4
    Email author
  • Pascal Villeneuve
    • 4
  • Ke Xu
    • 8
  1. 1.London School of Hygiene and Tropical MedicineLondonUK
  2. 2.Institute of International Health and DevelopmentQueen Margaret University CollegeEdinburghUK
  3. 3.World BankCabin JohnUSA
  4. 4.UNICEFNew YorkUSA
  5. 5.Ministry of HealthKampalaUganda
  6. 6.Institute of Tropical MedicineAntwerpBelgium
  7. 7.The World BankWashington, DCUSA
  8. 8.World Health OrganizationGenevaSwitzerland

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