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Health Policy and Planning, Vol 12, 273-285, Copyright © 1997 by Oxford University Press
L Gilson
This paper reviews the experience of implementing user fees in Africa. It
describes the two main approaches to implementing user fees that have been
applied in African countries, the standard and the Bamako initiative
models, and their common objectives. It summarizes the evidence concerning
the impact of fees on equity, efficiency and system sustainability (as
opposed to financial sustainability), and the key bottlenecks to their
effective implementation. On the basis of this evidence it then draws out
three main sets of lessons, focusing on: where and when to implement fees;
how to enhance the impact of fees on their objectives; and how to
strengthen the process of implementation.If introduced by themselves, fees
are unlikely to achieve equity, efficiency or sustainability objectives.
They should, therefore, be seen as only one element in a broader health
care financing package that should include some form of risk-sharing. This
financing package is important in limiting the potential equity dangers
clearly associated with fees. There is a greater potential role for fees
within hospitals rather than primary facilities. Achievement of equity,
efficiency and, in particular, sustainability will also require the
implementation of complementary interventions to develop the skills,
systems and mechanisms of accountability critical to ensure effective
implementation. Finally, the process of policy development and
implementation is itself an important influence over effective
implementation
ARTICLES
Review paper. The lessons of user free experience in Africa
Centre for Health Policy, Dept of Community Health, University of Witwatersrand, South Africa; Health Economics and Financing Programme, London School of Hygiene and Tropical Medicine, London, UK
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