Our Programmes



Sign up to our newsletter.

Follow ODI

How can the abolition of user fees and the provision of in-kind support impact on child poverty?

Time (GMT +01) 12:00 13:00


Dr Josef Decosas, Plan West Africa Regional Office

Francis Sathya, Plan International

Christina Behrendt, Social Security Department, International Labour Office

Angela Penrose, Grow Up Free From Poverty Coalition

The second meeting in the series was held on Wednesday 15th June 2005. The meeting was chaired by Angela Penrose and the three speakers were Josef Decosas, Francis V. Sathya and Christina Behrendt.

1. Josef Decosas observed that healthcare user charges in Africa were introduced in the 1980s based on two distinct justifications: to increase community ownership and as an alternative financing strategy. Over time these two objectives merged. He argued that increased investment in healthcare services in Africa impacted positively on the health of the population, especially that of children.

2. He focused on the case of Ghana, one of the first African countries to introduce health care user charges in the early 1980s. Studies had shown that user charges were a major deterrent in seeking healthcare services. Outpatient attendance rates initially dropped by 50 % in rural and urban areas. Although there was some recovery in urban areas after four years, the rates in rural areas had never recovered. The drop had greatest impact among the economically inactive. Children were left without access to services and there was a major fall in utilisation rates among older people. At the same time the proportion of users aged 15-45 increased from 27% to 42%. There was an increase in patients seeking traditional medicine, which allowed more flexible methods of payment, and in self-medication. Ghana was now to move to a universal health insurance system.

3. Josef Decosas outlined Plan's research on health equity in 5 communities in Senegal, Burkina Faso and Ghana. Plan developed 11 indicators and identified 5 social classes ranging from desperately poor to poor in the focus communities. One of the key findings was that the better off had better access to healthcare.

4. He looked at the case of child immunisation which was provided free of charge. Of 3,200 children in 2000 families, 90% were fully immunised. The households of the 242 unimmunised children identified the non-existence of the service or its lack of affordability as barriers to access. Poorer households were disproportionately affected by transport costs and waiting time which constituted access costs. While he concluded that free services were not sufficient to overcome inequity, Josef Decosas called for African governments and their donors to review the issue of user charges.

6. Francis V. Sathya reviewed desk research on user fees in primary education in 44 of the 45 countries where Plan had programmes. He looked at 3 sets of data: the percentage of the population living below the national poverty line, net primary school enrolments, and primary school completion rates. He found that 7 of the 44 countries offered no guarantee of free education. One of these 7, Niger had the lowest education indicators of all the countries surveyed.

7. He identified different forms of user fees. African countries tended to require a financial contribution to tuition fees, in East Asia user fees had often taken the form of financial contributions and uniforms, South Asian countries required tuition fees, text books and financial contributions, and in Latin America contributions were in the form of uniforms.

8. In his desk research Francis V. Sathya found no strong correlation between education user fees and enrolment or completion data. He identified a range of motives for poor parents investment in their children's educations including aspirational reasons, economic expectations and cultural or religious factors.

9. He concluded by questioning whether Plan's in-kind contributions had an impact on access to education and noted that Plan programme areas reported higher enrolment and completion rates than in non-Plan areas.

10. Christina Behrendt compared the arguments for cash and in-kind forms of social protection interventions. In-kind transfers were more easily targeted at those with greatest need, offered greater control over their use, had less inflationary impact on the local market, posed less of a security risk and were less prone to corruption and diversion. Cash allowed beneficiaries to decide on their priorities, had a strong stimulation effect on local market and were less prone to corruption if payments were regular and transparent and recipients were aware of their rights.

11. She then summarised an ILO study which examined the feasibility of low income countries to introduce a package of cash and in-kind transfers to ensure old age and disability pensions, child benefits, and universal access to basic healthcare and education. The simulated impact of such a package on Tanzania demonstrated that the most dramatic effects would be seen in 'missing generation households' which consisted of older people and children. A cash transfer targeted at the most vulnerable would see poverty rates in missing generation households drop from 47.6% to 5.4%.

12. The discussion that followed centred on the need for further research on the wider economic implications of cash and in kind transfers, in particular the impact on local inflation and equality. The negative impact of food relief on the local market was acknowledged while the inflationary effects of cash might be offset by stimulation of the local market. However it was pointed out that providing cash is pointless if there are no commodities to buy and that the potential vulnerability of transfer recipients at hands of the local elites should not be overlooked.

13. There was some discussion around an apparent orthodoxy around user fees. It was observed that successful experiences of high quality health services by fee-charging mission hospitals had led to the belief in quality being linked with charges. Religious factors meant drugs were less likely to be stolen, staff were committed and were paid, but these factors were ignored in assessing success.

14. The impact of user fees on the enrolment rates of girls in schools was debated. Conclusions were drawn on the importance of longitudinal studies.


Links between poverty and lack of access to basic services are uncontested, however there is a contentious debate about whether abolition of fees is the best way to increase accessibility. Lack of direct cost for the service may obscure the limits to accessibility imposed by related costs of related items or associated services. Plus abolition of fees does not address the issue of quality of the available services. Addressing these issues within a social protection package will increase the cost. This session presented Plan's research on the issue of user fees and discuss the best ways of delivering basic services that meet the needs of poor children. The key questions in this session focused on viability and affordability of the abolition of user fees, targeting mechanisms and the impact of such measures on quality.