Poverty and user fees for public health care in low-income countries: lessons from Uganda and Cambodia.

Public health systems in most low-income countries are unfair to poor people. Clearly preventive and curative public health-care services, especially hospital services, are accessed by poor people less frequently than by those who are better off . This injustice is now high on the international agenda. A solution for this issue has some global dimensions, such as the need for a large transfer of resources from high-income to low-income countries. Yet, in terms of the best use of these supplementary resources, defi nite solutions should be developed in every country. National policy makers have strategic choices to make in their eff orts to reach poor people. One option that policy makers might consider is the removal of the fees charged to users by public health facilities. A key strategy in the 1980s was user fees, which has been widely adopted in low-income countries. However, many studies have shown that the introduction of this policy has rarely been benefi cial to poor people.Abolishment of user fees in low-income countries has caused much debate, and international and aid agencies have been forced to take a position. However, a diff erence of opinion remains. The World Bank, an infl uential source of health-care fi nancing in developing countries, has confi rmed its analysis that user fees could be a necessary evil. This debate leaves national policy makers and fi nancial donors in disarray. The decision by the government of Burundi to remove user fees for pregnant women and children under 5-years old draws attention to an important point—user fee removal could result in sudden and radical policy changes, creating new hazards such as overcrowded wards, drug shortages, and overburdened staff . We identify some key issues that national policy makers will have to consider when making their own choices in policies for health-care fi nance that are favourable to poor people. We extract insights from the comparison between two experiences—the abolition of user fees in Uganda and the establishment of health equity funds in Cambodia. Although these two strategies are not the only alternatives, they mark the range of possibilities within the public sector and address a strategic question: should we allocate supplementary resources to universal solutions, or to interventions that target poor people?