Inequality in health care access is pervasive and well-documented around the world. Rich, educated city dwellers have consistently better access to care than poorer, less educated, and less urbanised people[1]. In sub-Saharan Africa, this inequality was exacerbated in the late 1980s by a general tendency to introduce, or increase, user fees in public facilities.

User fees were introduced as part of broader reform efforts to constrain public spending and establish new forms of revenue-generation for service providers. They were intended to improve the quantity and quality of care delivered. However, they raised financial barriers to access and diminished the utilisation of needed healthcare, especially for the poor[2].

Many governments in sub-Saharan Africa have in recent years acted to remove user fees, a policy supported by the WHO and the World Bank.

We know from fairly extensive literature that per capita utilisation tends to increase in a country following user fee removal[3]. But what do we know about the impact of this on the poor in particular?

There is much less data on this question and the emerging picture is a complex one. Although there is evidence that removing user fees increases utilisation amongst the poor most[4], this is not a consistent finding. For example, studies in Kenya[5] and Zambia[6] show that there was a shift in demand among the wealthy away from private providers towards public facilities after user fee removal. Hence, while financial barriers do impact on the health-seeking behaviour of the poor, the overall impact on equity of access remains unclear.

This complexity highlights the potential value of more research on this topic.

Relevant datasets for this research exist, too. Notably, Demographic and Health Surveys are available for almost every country in the African region. There would therefore appear to be scope for research that would improve the evidence on the equity outcomes from fee removal, and, equally importantly for the design and implementation of policy in particular contexts, the mechanisms through which these can be brought about.

Future research may focus on investigating the effects of such mechanisms on the rate at which the rural poor, or the urban poor, or the rural rich, or the urban rich are increasing their utilisation after user fee removal. A deeper understanding of such outcomes is crucial to inform future actions taken to achieve the Sustainable Development Goals.

Genevieve Hughes was an MSc student in GHPU in 2017-18. Her dissertation focused on user fee removal in the health systems of countries in Sub-Saharan Africa. 

[1] http://apps.who.int/iris/bitstream/handle/10665/43943/9789241563703_eng.pdf;jsessionid=7384DE652E352B26DCDAD95674B95BF6?sequence=1

[2] https://academic.oup.com/heapol/article/29/2/137/637405

[3] https://academic.oup.com/heapol/article/29/2/137/637405

[4] https://www.ncbi.nlm.nih.gov/pubmed/15746218

[5] https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-018-0774-4

[6] https://www.ncbi.nlm.nih.gov/pubmed/29034537

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