BMJ  2005;331:762-765 (1 October), doi:10.1136/bmj.331.7519.762

Education and debate

Removing user fees for primary care in Africa: the need for careful action

¹ Centre for Health Policy University of Witwatersrand, PO Box 1038, Johannesburg 2000, South Africa, ² Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Observatory, 7925, South Africa

Current calls for the removal of user fees respond to evidence of their regressive impacts and their role in enhancing social exclusion—but removal must be carefully managed because this action may have negative impacts on the wider health system

The first 150 words of the full text of this article appear below.

Introduction

User fees are once again a topic of hot policy debate in Africa. They were introduced relatively recently in many countries (box 1), but the current call is for their removal, particularly at primary care level.² As analysts who have consistently argued against user fees, we broadly support this call. However, we recognise that this action cannot be introduced overnight and, if weakly implemented, may exacerbate the problems facing African health systems. We outline both why we believe African countries should move away from user fees, and what actions should accompany their removal to ensure that this policy change strengthens rather than undermines healthcare provision. Our suggestions are based on the experience of countries such as South Africa and Uganda that have already removed some or all fees, as well as wider experience of policy change.

Why should fees be removed?

User fees are the most regressive form of healthcare financing available; they contribute to . . . [Full text of this article]

Mobilising and allocating resources

Effective implementation strategies

Conclusion

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