Abstract
This article analyzes the historical background of the institutionalization of user fees and their subsequent abolition in West Africa. Based on a narrative review, we present the context that frames the different articles in this supplement. We first show that a general consensus has emerged internationally against user fees, which were imposed widely in Africa in the 1980s and 1990s; at that time, the institutionalization of user fees was supported by evidence from pilot projects funded by international aid agencies. Since then there have been other pilot projects studying the abolition of user fees in the 2000s, but these have not yet had any real influence on public policies, which are often still chaotic. This perplexing situation might be explained more by ideologies and political will than by insufficient financial capacity of states.
Highlights
In this article, we present the general context of healthcare access in West Africa and interventions that have been aimed at improving access
We consider that the formulation of public policy results partly from a Correspondence: valery.ridde@umontreal.ca 1Department of Social and Preventive Medicine, University of Montreal School of Public Health, Montreal, Québec, Canada Full list of author information is available at the end of the article sustainability process, notably through actions implemented as pilot projects, for which a key outcome is the institutionalization of policy instruments [3,4]-in this case, related to user fees
There is a real discrepancy between the current state of knowledge on healthcare user fees and their abolition, on one hand, and how that knowledge is taken into account in public policies, on the other
Summary
Our aim in this analysis is to show that this interconnection has not yet been sufficiently effective, such that current user fee abolition policies are still not able to improve equity of access to the healthcare system. We have seen that, for political reasons, decision-makers balk at the pilot project approach, in the name of equal treatment for all, and because of the difficulty of explaining to citizens the value of such experiments Even when these experiments are taken into account, if the evidence shows that user fees do not make patients more ‘responsible’, or that exempting people from paying for drugs but not for consultations has only limited benefits, decision-makers often have trouble considering these facts. It showed that community complaints appeared to exert the greatest influence on decision-makers, yet these types of data are based on public opinion and not on information verified by research
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