Removing health user fees in sub-Saharan Africa: international debate, challenges of implementation, and health care seeking practices
Montreal University Hospital Research Centre (CR-CHUM), Canada!
n = 16 (30%)
n = 0
n = 7 (13%)
n = 30 (55%)
n = 1 (2%)
(incl. UNDP, UNICEF)
(incl. European Commission,
(The World Bank)
(incl. Canada, USA)
(incl. United Kingdom)
(incl. Gates Foundation)
(incl. Oxfam, Save the
Children, World Vision)
(incl. The Global Call to
Action Against Poverty)
(incl. The Global Coalition
on Women and AIDS)
(incl. Commission for Africa,
G8, People’s Health Movement)
Emilie Robert is a Ph.D. candidate in public health at the University of Montreal. She is a senior fellow of the Global Health Research Capacity Strengthening Program (GHR-CAPS). She was granted a scholarship from the
Faculté des Etudes Supérieures of the University of Montreal. Her doctoral thesis is supervised by Valéry Ridde, associate professor at the Department of social and preventive medicine at the University of Montreal.!
To identify disruptions in health systems
caused by user fee exemption policies
(UFEPs) in sub-Saharan Africa.!
Scoping study based on peer-reviewed
articles published in English or French,
between 1998 and 2009, reporting original
empirical data on UFEPs in sub-Saharan
Africa, and mentioning pressures or
disruptions in health system.!
Content analysis based on WHO framework
of six essential functions of health systems.!
To determine to what extent a consensus
exists among the various Global Health
Actors (GHAs) on the issue of user fees in
low- and middle-income countries (LMICs).!
Documentary study based on ofﬁcial and
public position statements available on the
Internet in English or French, published
between 2005 et 2011, addressing the issue
of development, poverty or healthcare in
LMICs, and ofﬁcially credited by a GHA.!
Stakeholder analysis using a decision tree +
Paying for health care is an expensive reality
for sub-Saharan populations, especially for
the most vulnerable who can rarely afford it.
This is why more and more countries in the
region abolish health user fees for certain
categories of population (e.g. pregnant
women, children under ﬁve, etc.) or for basic
health care. !
The objective of this thesis is to explore the
issues raised by removing health user fees in
sub-Saharan Africa, based on the conceptual
framework for globalisation and population
health by Huynen et al. (2005) (Figure 1). !
Huynen, M., Martens, P. & al. (2005). The health impacts of
globalisation: a conceptual framework. Globalization and Health 1:14.
Obrist, B., Iteba, N., & al. (2007). Access to Health Care in Contexts
of Livelihood Insecurity: A Framework for Analysis and Action. PLoS
Medicine 4(10):e308. !
Robert, E., Ridde, V., & al. (2012). Protocol: A realist review of user
fee exemption policies for health services in Africa. BMJ Open 2:
To understand how UFEPs inﬂuence health
care seeking practices in sub-Saharan
Realist review based on literature published
in French or English up to August 2013 on
UFEPs in sub-Saharan Africa.!
Theory-based analysis using a Context-
Mechanism-Outcome (CMO) framework
combining the Health Access Framework
(Obrist et al., 2005) and the ʻempowermentʼ
Health personnel Health information Drugs and vaccines Funding
Increase of workload
Insufficient medical staff
Loss of income
Lack of time for consultations
Feeling of being exploited,
Negative attitude of medical staff
Deterioration of staff morale
No information on:
- number and type of
- amount of
Shortages of drugs and
Delays and under-
Unpredictable, insufficient and
Loss of income and increased
debts for health centres
Reverting back to charging for
services and drugs
Difficulty to pay recurrent
Poor planning and
Poor understanding of
‘No blame game’
• 140 documents from 56 GHAs included.!
• Stances of GHAs presented in Table 1.!
• Arguments to justify stance: economic,
moral and ethical, and pragmatic.!
• Consensus, at least from a rhetorical
point of view, in favor of avoiding user
• Possible drivers of change in stance:
scientiﬁc knowledge, networks of actors,
• Words not systematically turned into
Source: Robert, E., & Ridde, V. (2013). Global health actors
no longer in favor of user fees: a documentary study.
Globalization and health 9: 29. doi:10.1186/1744-8603-9-29!
• 23 articles from 7 countries (Ghana,
Kenya, Madagascar, Senegal, South
Africa, Tanzania and Uganda) included.!
• Pressures synthesized in Table 2.!
• Risk of negative effects of UFEPs
because of bottlenecks.!
• Need for more empirical studies aimed at
understanding more clearly how UFEPs
affect, at one and same time, all the
functions of the health system.!
Source: Ridde, V., Robert, E., & al. (2012). A literature
review of the disruptive effects of user fee exemption
policies on health systems. BMC Public Health 12: 289. doi:
User fee exemption policy"
AVAILABILITY (C)! ADEQUACY (C)!
Beneﬁciaries seek free health
NORMS, POLICIES, INSTITUTIONS, AND
VULNERABILITY CONTEXT (C)! Preliminary results:"
• Results of theory-building process
presented in Figure 2.!
• 118 documents from 12 African countries
selected, and 66 included for theory-
• Preliminary CMO conﬁgurations in Box 1. !
• Economic, social and geographic
vulnerability, and resulting livelihood
assets, inﬂuence the degree of
empowerment that UFEPʼs target
populations have to seek free health care.!
Source: Robert, E., & Ridde, V. (2013). Lʼapproche réaliste
pour lʼévaluation de programmes et la revue systématique:
de la théorie à la pratique. Mesure et évaluation en
Conﬁguration 1: Availability of physical capital, such as proximity of health facilities,
availability of transport, and quality of road infrastructures (C), empowers the target
populations of the UFEP to seek free health care (M). Use of free health care is thus
Conﬁguration 2: In contrast, contexts of geographical vulnerability (C) undermine the
empowerment of the UFEPʼs target populations (M) and contribute to the renunciation
of free health care or to the use of other health providers (E).!
Conﬁguration 3: UFEPs target populations facing ﬁnancial hardship cannot afford the
indirect costs associated with accessing free health care (C), and this undermines their
empowerment to seek free health care (M). As a consequence, they may renounce free
health care, or chose other health providers (E).!
Conﬁguration 4: Beneﬁtting from social capital within the community or within health
facilities creates a context in which free health care is more accessible (whether
ﬁnancially, culturally or geographically) to the UFEPʼs target populations (C), which
strengthens their empowerment (M). As a consequence, they are more likely to seek
free health care (E). !
Conﬁguration 5: Conversely, the absence of social capital (C) undermines the
empowerment of the UFEPs target populations (M), discouraging them from seeking
free health care (E).!
Global governance !
Stance of Global Health Actors on
User fee exemption policies"
Health system and services!
Disruptive effects of user fee