Abolishing User Fees in Africa

In its 2008 annual report, the World Health Organization (WHO) urged countries to " resist the temptation to rely on user fees " [1, p. 26]. Indeed, the consensus in the scientific community is that user fees have harmful effects on health care use and household budgets, especially for the poorest [2]. Still, as the WHO observes, " …most of the world's health-care systems continue to rely on the most inequitable method for financing health-care services: out-of-pocket payments by the sick or their families at the point of service " [1, p. 24]. In Africa, where states lack either the will or the capacity to apply tax revenues to counter the exclusion caused by user fees, there are two broad alternatives to user fees at the local level. One alternative is to exempt from payment those who are permanently excluded from health care because they are too poor. The other is pre-payment schemes, where people are asked to pay before they need services. Community-based health insurance (CBHI) systems can be considered as one of these pre-payment modalities. In a randomised controlled trial in this issue of PLoS Medicine, Evelyn Ansah and colleagues examine the effects of free access to service through pre-payment schemes [3]. Their study is timely, since most international funding agencies seem prepared to support African states that remove user fees. Ansah and colleagues' study did not examine wide-scale national experiences of abolishing user fees, as happened in countries such as Niger and Uganda. Rather, the study was a pilot project on free access to a pre-payment scheme in the Dangme West District in southern Ghana. In the trial, 2,194 households containing 2,592 Ghanaian children under five years old were randomised into a pre-payment scheme allowing free primary care, or into a control group whose families paid user fees for health care (normal practice). The study also included an observational arm made up of 165 children whose families had previously paid to enrol in the pre-payment scheme. The primary outcome was moderate anaemia (haemoglobin [Hb] < 8 g/dl); secondary outcomes were health care utilisation, severe anaemia, and mortality. Moderate anaemia was detected in 37 children (3.1%) in the control arm and 36 children (3.2%) in the intervention arm (adjusted odds ratio 1.05, 95% confidence interval [CI] 0.66–1.67). There were four deaths in the control and five in the intervention group. Mean Hb concentration, severe anaemia, parasite prevalence, and …