Removing user fees in the health sector: a review of policy processes in six sub-Saharan African countries

In recent years, governments of several low-income countries have taken decisive action by removing fully or partially user fees in the health sector. This study reviews recent reforms in six sub-Saharan African countries: Burkina Faso, Burundi, Ghana, Liberia, Senegal and Uganda. The review describes the processes and strategies through which user fee removal reforms have been implemented and assesses them.
The analysis shows that African leaders are willing to take strong action to remove financial barriers met by vulnerable groups, especially pregnant women and children. However, due to a lack of consultation and the often unexpected timing of the decision taken by the political authorities, there was insufficient preparation for user fee removal in several countries. This lack of preparation resulted in poor design of the reform and weaknesses in the processes of policy formulation and implementation.
‘There is now a window of opportunity in many African countries for policy action to address barriers to accessing health care. Mobilising sufficient financial resources and obtaining long-term commitment are crucial requirements, but design details, the formulation process and implementation plan also need careful thought’ (p.ii16). Donors should now shift from focusing on agenda-setting role to an emphasis on technical support. A key priority is to improve the sharing of lessons and experiences and developing a community of practice in this area.