This booklet follows a study of ways and means to promote universal access to health care when the main objective of user fees is to generate revenue reported in its companion book, 'Ensuring Equal Access to Health Services: User Fee Systems and the Poor', reviewed above. It takes the findings a step further, presenting guidelines for use in decisions specifically about whether exemption mechanisms should be a mandatory component of user fee systems in public health facilities. The authors are optimistic that these guidelines will: (a) lead policy makers and health system managers to discuss user fees and equity issues; (b) help in exploring measures for promoting access of poor to services; and (c) offer guidance on developing, implementing and managing such mechanisms. For policy makers concerned with the design of user fee systems, this is an essential resource. The booklet draws on the same five country case studies (Ecuador, Indonesia, Kenya, Tanzania and Guinea) presented in the earlier book to make and illustrate the arguments.
This booklet offers a useful background to the rationale and emergence of user fees dominant among methods of drawing private finance into the public system. As such schemes have become more widespread, decreased use of services by the poor has caused concern that the poor are being denied access because of fees.
The main findings of studies conducted in five countries in a nutshell in this booklet, and it is useful simply for this concise briefing. The poor often pay for care when services are supposed to be free; patients total costs for health services include much more than user fees, creating an additional barrier for the poor; paying for health care may undermine the ability of the poor and marginally non-poor households to afford the costs of all their basic needs, although they are willing to pay for high quality services; the poor lack information and receive misinformation about the waiver systems. The authors have also argue that, despite wide disparities in social, cultural and economic circumstances, and different health systems in case study countries, the basic issues are the same and their suggested solutions apply.
Different types of payment schemes are discussed and a clear distinction is drawn between user fees and co-payments. A list of conditions for generating revenues from the user fees, such as fee levels; the quality of paid and free services; and, the efficiency of collection is reviewed and the arguments match findings of other studies: for example, quality improvements (e.g. enhanced availability of drugs)