User feesLimited success at managing demandProfound effects on access

BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7102.202 (Published 26 July 1997) Cite this as: BMJ 1997;315:202

User fees

They don't reduce costs, and they increase inequity

If user fees for health care are the solution, what exactly is the problem? Proponents of user fees recommend them in two situations. The first is when health spending in total is low or falling—fees are recommended as a way to mobilise more money for health care than existing sources provide. The second, paradoxically, is when health expenditure is high or rising quickly, when fees are recommended as a way of improving efficiency by moderating demand and containing costs.1 2 Opponents of user fees attack them as a political strategy for shifting healthcare costs from the better off to the poor and the sick, pointing to the trade off between this method of raising revenue and maintaining access to care based on need rather than ability to pay.3

Dramatic differences exist between countries. Levels of and trends in national income and the condition of health systems vary widely among countries, and local context needs to be considered when making comparisons. In many “transition” economies such as China, Kyrgyzstan, Georgia, and Vietnam formal and informal charging at “subsidised” (government) health facilities has been used to replace sharply declining public sector funds. In most of the very poor …

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