This week, we welcome and editorial from Abdelmajid Tibouti who highlights the importance of the just launched supplement in Health Policy and Planning on the removal of user fees in developing countries in the current context.
In recent years, many governments have taken bold actions for improving financial access to basic health services. A common trend has been the removal of user fees for services targeting some vulnerable groups, especially children under five and pregnant women.
In view of this emerging trend, UNICEF approached in mid-2008 a group of researchers led by the Antwerp Institute of Tropical Medicine with the request to document recent country experiences with user fee removal. While aid actors in the North were still arguing fiercely about the pros and cons of user fees, a consensus was easily reached between UNICEF and the research team: the multi-country review would not (again) focus on evidence against or in favour of user fees, but would instead try to document how countries formulated and implemented user fee removal policies. This focus was seen as valuable because it could generate practical lessons for other countries interested in such a step.
The findings of the multi-country review were shared at a global consultation convened by UNICEF New York in February 2009. One of the conclusions of the consultation was that the main question of the multi-country review – the challenges related to design and implementation of user fee removal policies – deserved more visibility than just another report. Indeed, while there is a large consensus among experts familiar with health systems in low-income countries that implementation of new policies and interventions raises major challenges, the formally published knowledge base was still small.
To some extent, our hopes materialised. Bruno Meessen, Lucy Gilson and myself were able to coordinate this Health Policy and Planning Supplement. We adopted a pragmatic approach based on the belief that there was no blueprint for removing financial access barriers; and that policy outcomes depend on how policies are designed and implemented.
Indeed, a key strength of the country experiences reviewed in this supplement is the clear leadership displayed by political leaders. When such leadership was coupled with smooth dialogue with programme managers, the formulation of the reform benefited greatly. However, the eagerness of the political leaders to move rapidly has also sometimes confronted programme managers with the obligation to implement an insufficiently prepared decision.
Once the decision has been taken to remove user fees, a series of implementation challenges arise, many of which were identified through the case studies. These include areas of weak policy design (e.g. failure to consider incentives and unintended consequences of the policy, identifying the correct level of reimbursement of health providers) and weak policy implementation (e.g. securing the resources needed to communicate the policy to front line health workers and to the population).
The policy outcome of these decisions depends on how these challenges are addressed. As shown by some country experiences documented in this supplement, the policy process of fee elimination can play a catalytic effect in forcing Governments to confront other issues such as drug supply and procurement, staff workload and motivation, budget allocation and financial management. When this happens, fee removal provides a useful entry point to discussions about health systems strengthening, in particular through the attention it draws to ensuring availability of essential drugs in the face of increased utilization, strengthening the incentives that health workers face as a result of increased workloads, and improving the mechanisms of accountability within the health system.
There is, therefore, a need for much better learning. Within countries, there is a need for monitoring and evaluation, to allow course corrections; and between countries, there is a need to share lessons of experience and best practice. In measuring the effects of such a policy it is also important to look beyond the impact on aggregate utilization to examine the effects specifically on the poor, on quality of services, and on the extent to which health systems are able to sustain initial increases in utilization.
We hope that this supplement has made a good first step in this direction.
Abdelmajid Tibouti, Ph.D.
Senior Adviser, Programme Division
United Nations Children’s Fund