User fee removal in low-income countries: sharing knowledge to support managed implementation.

User fees have triggered impassioned discussions in international health over the last two decades. Promoted by a number of international organizations since the late 1980s as a strategy to finance struggling public health facilities in many lowincome countries, recent years have seen growing criticism of the impact of fees on access to health services, particularly for the poorest groups. The debate continues and there is evidence for both sides of the argument. User fees are a barrier to users, and the poor in particular, but they also have some valuable characteristics (Meessen et al. 2006). Their contribution to generating resources for the benefit of health facilities that are sometimes deprived of any other source of flexible funding is just the most obvious one. Taking the right stance in this debate is far from easy for countries and their aid partners, as different constraints—including country ownership, fiscal space, other pressing development needs and the obligation to ration available resources—have to be taken into account. In 2005, UNICEF organized an expert consultation to update its position on this controversial strategy. The evidence reviewed at this consultation led to the following consensus: removing user fees has the potential to improve access to health services, especially for the poor. For this to occur, however, fee removal needs to be part of a broader package of reforms that includes increased budgets to offset lost fee revenue, maintain quality and respond to increased demand. It also needs clear communication with a broad stakeholder buy-in, careful monitoring to ensure that official fees are not replaced by informal fees, and appropriate management of the alternative financing mechanisms which are replacing user fees. When the above conditions are not met, fee removal is unlikely to benefit the poor (James et al. 2006). In mid-2008, UNICEF approached a group of researchers with the request to document recent experience with user fee removal. While aid actors in the North were still arguing fiercely about the pros and cons of user fees, a growing number of countries had already decided to remove user fees, at least for some priority services. A consensus was easily reached between UNICEF and the research team led by the Institute of Tropical Medicine, Antwerp: 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. 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 presented at a meeting of experts convened by UNICEF New York in February 2009. Presentations covered a number of countries as well as comparisons between countries—including a challenging comparison between Rwanda and Uganda. At some point, the ‘ghosts’ of Bismark and Beveridge entered the room, so there was another episode in the (by now familiar) debate on the relative merits of reducing financial barriers through health insurance or through user fee removal. We do have some country evidence to fuel this broader debate in this supplement; however, its main focus lies elsewhere. Following the New York meeting, the research team judged 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 (Peters et al. 2009), the formally published knowledge base is still small (Gilson and Raphaely 2008). Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine The Author 2011; all rights reserved. Health Policy and Planning 2011;26:ii1–ii4 doi:10.1093/heapol/czr071