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American Journal of Public Health Research. 2013, 1(8), 196-202
DOI: 10.12691/ajphr-1-8-1
Open AccessReview Article

The Impacts of User Fees on Health Services in Sub-Saharan African Countries: A Ctirical Analysis of the Evidence

Ejughemre Ufuoma John1,

1Department of Community Medicine, Delta State University Teaching Hospital, Oghara, Delta State, Nigeria

Pub. Date: September 16, 2013

Cite this paper:
Ejughemre Ufuoma John. The Impacts of User Fees on Health Services in Sub-Saharan African Countries: A Ctirical Analysis of the Evidence. American Journal of Public Health Research. 2013; 1(8):196-202. doi: 10.12691/ajphr-1-8-1


The momentum towards achieving the United Nations Millennium Development Goals re-invigorated concerns around sustainable health care financing and the adequacy of the financing arrangements in many low-resource settings. Accordingly, this necessitated the institution of user-fees as part of health financing reform in many countries in sub-Saharan Africa. These fees are charges levied at the point of service with the intent of reducing ‘frivolous’ consumption of health services, increasing the quality of services available and at the same time increasing coverage and utilisation of services. Likewise, as a ‘decisive’ policy to cushion the existing challenges facing health care financing in the region, a critical assessment of the assertions of proponents of user fees who use the principle of cost recovery and revenue mobilization to drive the concept of rational utilization, efficiency and equitable distribution of health care services is often exaggerated. As it were, the available evidence suggests that user fees alone will not likely accomplish equity, efficiency, or the sustainability objectives in health services in the region. What is critical is that user fees should be linked to the broader package of financing -such as insurance coverage- and with a view to averting any form of equity danger that may thus arise.

user-feesutilization equity quality health services sub-Saharan Africa

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[1]  Meessen B., Hercot D, Noirhomme M., Ridde V., Tibouti A, Bicaba A.,Kirunga C., Tashobya and Lucy Gilson.Removing user fees in the health sector: A Multi-Country Review. United Nations Children's Fund (UNICEF), 2009.
[2]  Waiswa W.P. The impact of user fees on access to health services in low- and middle-income countries: RHL commentary (last revised: 1 May 2012). The WHO Reproductive Health Library; Geneva: World Health Organization.
[3]  Meessen B, Hercot D, et al. Removing user fees in the health sector: a review of policy processes in six sub-Saharan African countries. Health Policy and Planning 2011; 26(20):16-29.
[4]  McPake B. User charges for health services in developing countries: a review of the economic literature. Social Science and Medicine, 1993. 36; 11:1397-405.
[5]  World Bank 1987. World Bank. Financing the health sector: an agenda for reform. Washington, DC: The World Bank, 1987.
[6]  World Bank. 1993. World Development Report 1993: Investing in Health. New York: Oxford University Press.
[7]  Griffin, C.. “Welfare Gains from User Charges for Government Health Services.” Health Policy and Planning 1992. 7(2):177-180.
[8]  Shaw, P., Griffin C. Financing Health Care in Sub-Saharan Africa through User Fees and Insurance. Washington, D.C.: World Bank. 1995.
[9]  Third World Network: World Bank and IMF are responsible for Africa’s Health Crisis. 2002. Available online at < > Accessed 6th July,2013.
[10]  World Health Organization (WHO). Evaluation of Recent Changes in the Financing of Health Services: Report of a WHO Study Group. Technical Report Series No. 829. Geneva: WHO. 1993.
[11]  Dumoublin, J., Kaddar M., Velasquez G. Access to Drugs and Finance: Basic Economic and Financial Analysis. WHO/DAP/91.5. Geneva: World Health Organization. 1991.
[12]  Griffin C. User Fees For Health In Principle And Practice. EDI Seminar Project. World Bank. Washington DC,1987.
[13]  Shepard and Benjamin. User Fees in Health Financing in Developing: mobilizing financial resources for health. In Health Nutrition and Economics crises: Approaches to policy in the third world. Bell D Reich M (eds). Auburn House Publishing Company. Dover MA. 1988.
[14]  Mwanbu G. Financing Health Services in Africa: an assessment of alternative approaches. PRE working paper 457. World Bank: Washington DC,1990.
[15]  Diop F, Yazbeck A, Bitran R. The impact of alternative cost recovery schemes on access and equity in Niger. Health Policy and Planning 1995;10(3):223-40.
[16]  Bratt JH, Weaver MA, Foreit J, De Vargas T, Janowitz B. The impact of price changes on demand for family planning and reproductive health services in Ecuador. Health Policy and Planning 2002;17(3):281-7.
[17]  Issifou S, Kremsner PG. Impact of increasing consultation fees on malaria in Africa. Wiener Klinische Wochenschrift 2004;116(9-10):332-3.
[18]  Bennett S. The Impact of the increase in user fees: A preliminary investigation. Lesotho Epidemiological Bulletin.1989; 4:29-37.
[19]  Lagarde M., Palmer N. The impact of user fees on access to health services in low and middle-income countries. Cochrane Database of Systematic Reviews 2011; 4.
[20]  Abdu Z, Mohammed Z, Bashier I, Eriksson B. The impact of user fee exemption on service utilization and treatment seeking behaviour: the case of malaria in Sudan. International Journal of Health Planning and Management 2004;19(1):95–106.
[21]  Moses S, Manji F, Bradley JE, Nagelkerke NJ, Malisa MA, Plummer FA. Impact of user fees on attendance at a referralcentre for sexually transmitted diseases in Kenya. Lancet 1992;340(8817):4636.
[22]  Collins D, Quick J, Musau S, Kraushaar D, Hussein I. The fall and rise of cost sharing in Kenya: the impact of phased implementation. Health Policy and Planning 1996;11(1): 52-63.
[23]  Wilkinson D, Gouws E, Sach M, Karim SS. Effect of removing user fees on attendance for curative and preventive primary health care services in rural South Africa. Bulletin of the World Health Organization 2001; Vol. 79, issue 7: 665-71.
[24]  Burnham G, Pariyo G, Galiwango E, Wabwire-Mangen F. Discontinuation of cost sharing in Uganda. Bulletin World Health Organization 2004; Vol. 82, issue 3:187-95.
[25]  Meessen, B. Removing user fees in the health sector in low-income countries: A policy guidance note for program managers. UNICEF, New-York. 2009.
[26]  Abel-Smith, B., and P. Rawall. “Can the Poor Afford ‘Free’ Health Care: A Case Study of Tanzania.” Health Policy and Planning. 1992;7(4):329-41.
[27]  Stanton B., Clemens J. User Fees for Health Care in developing countries: A case study of Bangladesh. Social Science and Medicine. 1988, 39(8):1105-1115.
[28]  Russell, S., and L. Gilson. “User Fees in Government Health Services: Is Equity Being Considered? An International Survey.” PHP Publication no. 15. London: London School of Hygiene and Tropical Medicine. 1995.
[29]  Seperhi A., Chernomas R. Are User Charges Enhancing Efficiency and Equity Enhancing? A Critical Review of the Economic Literature with particular reference to experience from developing countries. Journal of International Development. 2001; 13:183-209
[30]  Baker J., van de Gaag, J. Equity in health care and health care financing. Evidence from five developing countries. In Equity in the Finance and delivery of health care: An International Perspective. Oxford University Press.1993.
[31]  de Ferranti. Paying for a Health Services in Developing countries: An Overview. Staff working paper,721. World Bank, Washington DC.1985.
[32]  Meessen B, Zhenzhong Z, van Damme W et al. Editorial: Iatrogenic poverty. Tropical Medicine and International Health. 2003; 8: 581-4.
[33]  Frenk J, Gonzalez-Pier E, Gomez-Dantes O, Lezana MA, Knaul F. Comprehensive reform to improve health system performance in Mexico. The Lancet. 2006; 368: 1524-34.
[34]  Booth D.,et al. Coping with cost recovery: a study of the social impact of and response to cost recovery in basic services (health and education) in poor communities in Zambia.1995.
[35]  Gilson, L., S. Russell, and K. Buse. “The Political Economy of User Fees with Targeting: Developing Equitable Health Financing Policy.” Journal of International Development. 1995; 7(3):369-402.
[36]  World Health Organization. Guideline for Implementing the Bamako Initiative. Regional Committee for Africa, thirty eight session, Brazaville.7-14 September,1988.AFR/RC38/18. WHO: Geneva.
[37]  Chabot J. Effect of a drug and sharing system on prescribing and utilization. A controlled trial from Nepal. Health Policy and Planning. 1995; 10(4):423-430.
[38]  Vogel R. Cost Recovery in the Health Sector in Sub-Saharan Africa. International Journal of Health Planning Management. 1991; 6:167-191.
[39]  Norlan B., Tublat V. Cost Recovery in Public Services in Sub-Saharan Africa.EDI Seminar Series. World Bank, Washington DC.1995.
[40]  Kutzin, J. “Experience with Organisational and Financing Reform of the Health Sector.” Current Concerns Strengthening Health Services Paper no. 8. WHO/SHS/CC94.3. Geneva: World Health Organization. 1995.
[41]  Gilson, L., and A. Mills. “Health Sector Reforms in Sub-Saharan Africa: Lessons of the Last 10 Years.” Health Policy 1995. 32(1-3):215-43.
[42]  McPake, B., K. Hanson, and A. Mills. 1992. “Implementing the Bamako Initiative in Africa: A Review and Five Case Studies.” PHP Departmental Publication no. 8. London: London School of Hygiene and Tropical Medicine.
[43]  Oakely P. Community Involvement in Health Development: An Examination of the Critical Issues. World Health Organization. Geneva. 1989.
[44]  Gilson, L. “Government Health Care Charges: Is Equity Being Abandoned?” EPC Publication no. 15. London: London School of Hygiene and Tropical Medicine. 1995. “Management and Health Care Reform in Sub-Saharan Africa.” Social Science and Medicine. 1988; 40(5):695-710.
[45]  Lupton D. The Imperative of Health: Public Health and the regulated Body. Sage. London.1995.