Failure of User Fees

Abstract

The end of health care user fees is within sight for an increasing number of African countries whom this policy was imposed upon in the late 1980 and early 1990s. User fees were part of structural adjustment programs (SAPs) dictated to developing countries by the World Bank, influenced by the Bamako Initiative. The West African country of Mali is presently working towards eliminating user fees and implementing Universal Health Care (UHC). This paper investigates health indicators of pregnant women in Mali during user fee implementation to show the negative impact of the policy, and extrapolates to future outcomes when UHC is available. For example, when user fees were removed in pilot projects, Caesarean costs decreased from 95-136 $USD to 0.80-10 $USD, and Caesarean rates increased by a factor of 2.5. As well, with user fees, Malian citizens had to pay an average of 2 months of salary per health care visit, severely limiting those who could access services. These numbers show that vulnerable individuals in Mali, such as expecting mothers, likely experience unmet need for healthcare services in Mali, and the current user fees system is insufficient and inequitable.