THE LESSONS OF USER FEE EXPERIENCE IN AFRICA

This paper reviews the experience of implementing user fees in Africa. it describes the two main approaches to implementing user fees that h ave been applied in African countries, the standard and the Bamako Ini tiative models, and their common objectives. It summarizes the evidenc e concerning the impact of fees on equity, efficiency and system susta inability (as opposed to financial sustainability), and the key bottle necks to their effective implementation. On the basis of this evidence it then draws out three main sets of lessons, focusing on: where and when to implement fees; how to enhance the impact of fees on their obj ectives; and how to strengthen the process of implementation. if intro duced by themselves, fees are unlikely to achieve equity, efficiency o r sustainability objectives. They should, therefore, be seen as only o ne element in a broader health care financing package that should incl ude some form of risk-sharing. This financing package is important in limiting the potential equity dangers clearly associated with fees. Th ere is a greater potential role for fees within hospitals rather than primary facilities. Achievement of equity, efficiency and, in particul ar, sustainability will also require the implementation of complementa ry interventions to develop the skills, systems and mechanisms of acco untability critical to ensure effective implementation. Finally, the p rocess of policy development and implementation is itself an important influence over effective implementation.