There is wide-spread evidence to show that fees encourage self-treatment (using herbs or poor quality medicine bought in unregulated marketplaces), deter people from taking full doses (so increasing the chances of drug resistance), and act as a barrier to early, or even any, use of health facilities.

EQUINET

User fees are once again a hot topic of policy debate. This time the question is whether to remove primary care fees. At its conference in June this year, EQUINET took a clear position on the issue. We called for these fees to be removed. But we also stated that this action is not a cure-all for the problems facing health systems in Africa. User fee removal must be accompanied by actions that increase overall national resources for public sector health services and that deal with international conditions and policies that undermine this.

The two reasons why primary care fees must go are that:

1 They contribute to the unaffordable cost burdens imposed on poor households;

2 They signal to poor households that society does not care about them.

Fees at primary care are relatively low. Even so, there is wide-spread evidence to show that fees encourage self-treatment (using herbs or poor quality medicine bought in unregulated marketplaces), deter people from taking full doses (so increasing the chances of drug resistance), and act as a barrier to early, or even any, use of health facilities. In these ways the small level of fees can increase the costs poor people bear when ill. So even though fees represent a smaller proportion of the total costs of accessing health care than transport or lost income,they contribute to levels of cost burden that can, in some in-stances, impoverish poor households. At one level, impoverishment results from selling key assets, cutting down on other necessary expenditures, or borrowing, often at exorbitant interest rates, to pay for health care. At another level, charging fees adds cost to the other immense barriers of accessing care, such as distance and abusive treatment. It signals to poor people that they are not valued or cared for by society.

However, removing primary care fees is not enough by itself to tackle the range of existing health care challenges in Africa. Other actions are also required.

First, the levels of funding available for health care must be increased. At least 15% of government budgets should be invested in the public health sector, as committed by African governments in Abuja. Only one country in southern Africa, Mozambique, is currently reported to be achieving this. This will support the sustained quality increases necessary to improve health system performance, as well as allowing the system to respond effectively to the utilization increases likely to result from fee removal.

Linked to this African country debt should be cancelled. The EQUINET June 2004 Conference called for international action to remove the debt burdens imposed on African countries, and for national action to increase the level of government funding to health systems. These changes in financing also need to be underpinned by changes in terms of trade for African countries that result in huge resource outflows from Africa, including market barriers in industrialized countries to trade in food products and the poaching of health personnel.

Second, the removal of fees must be undertaken in a way that actively strengthens the health system. In particular, the responses of health workers and managers must be deliberately managed to avoid negative impacts on morale and performance. As front-line providers and managers are the point at which patients meet the health system, their morale and performance has a direct influence over how patients experience health care, and how policies are implemented. In South Africa,while the removal of fees had a powerful positive effect on health outcomes, health workers said they were not adequately informed or involved, and were thus unprepared for the resulting increases in utilization. This can lead to unnecessary tensions at primary care level, and patients complaining that health workers treat them badly. In countries where fees have been retained, they have allowed managers and local communities some control over the decision of how to use the revenue. In others they have been used to fund agreed incentives for staff. These issues need to be managed and alternative ways found of providing for local resource control and staff incentives to avoid demoralisation.

Experience from a wide range of policy actions indicates that managing this policy change must involve:

• 1. Giving a specific government unit the task of implementing fee removal in ways that strengthen the health system;
• 2. An effective public relations campaign to communicate the change with the general public, and to signal that removal of fees is about valuing patients and providers;
• 3. Ensuring that the policy goals are clearly explained to man-agers and health workers to promote support for the policy at all levels of the health system;
• 4. Preparatory planning to ensure adequate levels of drug and staff availability to cope with the likelihood of initial utilization increases -and longer-term planning for how to tackle wider drug and staffing, including motivation, problems;
• 5. Establishing new, manager-controlled funds at local level that allow management freedom on small-scale spending decisions;
• 6. Clear communication with health workers and managers about what and when actions will be taken - through meetings, supervision visits, special information letters;
• 7. Expect that there will be unanticipated problems with implementation, and so set up monitoring systems that provide a basis for identifying what other actions need to be taken: monitoring utilization trends, including the relative use of preventive versus curative care, and giving health workers and managers opportunities to feed back on health facility experiences.

Tackling the human resource barriers to effective fee removal will inevitably require the wider action that is necessary to address the overall human resource crisis in Africa. On this issue EQUINET has called for human resource policies and measures at national, regional and international level that promote the retention and improved working conditions of health personnel in public sector health systems, backed by compensation for regressive south-north subsidies incurred through health personnel migration. An editorial later this year will provide more detail on this.

User fee removal clearly provides an opportunity to begin to address the needs of poor people. However, their removal is not enough by itself. EQUINET calls for this to be backed at national level by increased public financing for health and at international level by a cancellation of debt. In addition, user fee removal must be implemented in ways that strengthen the health system. User fees were actively promoted internationally during periods of efficiency and market led health sector reforms that produced a huge cost to equity in health in southern Africa. User fee removal must be underpinned by actions at international and national levels that provide for the resources to achieve human rights to health and health equity goals.