Global health actors no longer in favor of user fees: a documentary study.

Emilie Robert,Valéry Ridde

doi:10.1186/1744-8603-9-29

Abstract

BackgroundSince the advent of health user fees in low- and middle-income countries in the 1980s, the discourse of global health actors (GHAs) has changed to the disadvantage of this type of healthcare financing mechanism. The aim of the study was to identify and analyze the stance of GHAs in the debate on user fees.MethodsWe conducted documentary research using public documents published by and officially attributed to GHAs from 2005 to 2011. We categorized GHAs into four groups: intergovernmental organizations, international non-governmental organizations, government agencies, and working groups and networks. We then classified the GHAs according to their stance relative to the abolition of user fees, and conducted a thematic analysis of their discourse to understand the arguments used by each GHA to justify its stance.ResultsWe identified 56 GHAs, for which we analyzed 140 documents. Among them, 55% were in favor of the abolition of user fees or in favor of free care at the point of delivery. None of the GHAs stated that they were in favor of user fees; however, 30% did not take a stand. Only the World Bank declares that it is both in favor of user fees and in favor of free care at point of service. GHAs generally circumscribe their stance to specific populations (pregnant women, children under 5 years, etc.) or to specific health services (primary, basic, essential). Three types of arguments are used by GHAs to justify their stance: economic, moral and ethical, and pragmatic.ConclusionsThe principle of “user pays” seems to have fizzled. Production and dissemination of evidence, as well as certain advocacy networks, may have contributed to this change in discourse. However, GHAs should go a step further and translate their words into action, so that free healthcare at the point of delivery becomes a reality in low- and middle-income countries. They should provide technical and financial support to those countries that have chosen to implement user fee exemption policies, sometimes influenced by a GHA.

Highlights

Since the advent of health user fees in low- and middle-income countries in the 1980s, the discourse of global health actors (GHAs) has changed to the disadvantage of this type of healthcare financing mechanism
Universal health coverage is the new objective of the decade [1] and several low-and middle-income countries (LMICs), such as India and Ghana, are testing the principle of sharing the financial risks linked with access to healthcare
Description of the GHAs and included documents We identified 56 GHAs: 18 were intergovernmental organizations, 10 were government agencies, 8 were international non-governmental organizations and 20 were working groups and transnational networks

Summary

Introduction

Since the advent of health user fees in low- and middle-income countries in the 1980s, the discourse of global health actors (GHAs) has changed to the disadvantage of this type of healthcare financing mechanism. Universal health coverage is the new objective of the decade [1] and several low-and middle-income countries (LMICs), such as India and Ghana, are testing the principle of sharing the financial risks linked with access to healthcare. Such policies are few in number, especially in Africa [2], and user fees remain a widespread health financing mechanism [3,4]. The evidence is mixed [11,15], showing, for example, that quality of care improved in some settings

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