USER FEE POLICIES TO PROMOTE HEALTH-SERVICE ACCESS FOR THE POOR - A WOLF IN SHEEPS CLOTHING

An international survey of health service user fee and exemption polic ies in 26 low- and middle-income countries assessed whether user fee p olicies were supported by measures that protect the poor. In particula r, it explored whether governments were introducing a package of suppo rtive measures to promote service improvements that benefit disadvanta ged groups and tackle differential ability to pay through an effective series of exemptions. The results show that many countries lack polic ies that promote access for disadvantaged groups within user fee syste ms and quality improvements such as revenue retention at the health ca re facility and expenditure guidelines for local managers. More signif icant policy failures were identified for exemptions: 27 percent of co untries had no policy to exempt the poor; in contrast, health workers were exempted in 50 percent of countries. Even when an official policy to exempt the poor existed, there were numerous informational, admini strative, economic, and political constraints to effective implementat ion of these exemptions. The authors argue that user fee policy should be developed more cautiously and in a more informed environment. Fees are likely to exacerbate existing inequities in health care financing unless exemptions policy can effectively reach those unable to pay.