Removing user fees in the health sector: a review of policy processes in six sub-Saharan African countries

• Published in: Health policy and planning Vol. 26; no. suppl_2; pp. ii16 - ii29
• Main Authors: Meessen, Bruno, Hercot, David, Noirhomme, Mathieu, Ridde, Valéry, Tibouti, Abdelmajid, Tashobya, Christine Kirunga, Gilson, Lucy
• Format: Journal Article
• Language: English
• Published: England Oxford University Press 01.11.2011; Oxford Publishing Limited (England)
• Subjects: Africa South of the Sahara; Africans; Authority; Burkina Faso; Burundi; Children; Decision making; Developing countries; Fees; Fees & charges; Fees and Charges; Financial reforms; Ghana; Health; Health administration; Health care; Health care access; Health care policy; Health policy; Health Services Accessibility - economics; Humans; Hypothesis; International agencies; LDCs; Liberia; Low income countries; Low income groups; Manycountries; Medical service; Original articles; Policy Making; Politics; Pregnant women; Public Policy; Reforms; Studies; Sub-Saharan Africa; Uganda; User fees; Women; Africa South of the Sahara; Sub-Saharan Africa; policy process; User fees; health financing
• ISSN: 0268-1080; 1460-2237
• DOI: 10.1093/heapol/czr062

In recent years, governments of several low-income countries have taken decisive action by removing fully or partially user fees in the health sector. In this study, we review recent reforms in six sub-Saharan African countries: Burkina Faso, Burundi, Ghana, Liberia, Senegal and Uganda. The review describes the processes and strategies through which user fee removal reforms have been implemented and tries to assess them by referring to a good practice hypotheses framework. The analysis shows that African leaders are willing to take strong action to remove financial barriers met by vulnerable groups, especially pregnant women and children. However, due to a lack of consultation and the often unexpected timing of the decision taken by the political authorities, there was insufficient preparation for user fee removal in several countries. This lack of preparation resulted in poor design of the reform and weaknesses in the processes of policy formulation and implementation. Our assessment is that there is now a window of opportunity in many African countries for policy action to address barriers to accessing health care. Mobilizing sufficient financial resources and obtaining long-term commitment are obviously crucial requirements, but design details, the formulation process and implementation plan also need careful thought. We contend that national policy-makers and international agencies could better collaborate in this respect.