Skip to main content

Volume 15 Supplement 3

User Fee Exemption Policies


Universal Health Coverage (UHC) is increasingly gaining centre stage in the post 2015 international development agenda [1]. After years of debate [24], a consensus has gradually emerged that UHC is "an affordable dream" [5] that can have a significant impact on people's individual and collective wellbeing. Comprehensive monitoring frameworks to measure progress towards UHC are being developed [6]. Eventually, UHC is seen as a vehicle to bring about health equity [7].

The concern for equity in health is of course all but new [8]. However, equity as a moral imperative has not always been a prime concern in health financing [9]. Back in the 1980s, efficiency was the dominant driver of health financing reforms under structural adjustment. Corrective measures such as fee exemptions for indigents followed, but rarely proved to be effective [1012]. To this added a growing body of evidence on the negative impact of user fees on health equity [1316]. It is thus no wonder that the UHC debate at the beginning of the 21st century renewed and boosted interest in equity [1720].

Designing and implementing equity-oriented strategies remains, however, a key challenge in low- and middle-income countries [21]. Policymakers and implementers increasingly demand practical insights and knowledge [22], on which the otherwise copious UHC literature is particularly silent. Jim Yong Kim, President of the World Bank, recently made a case for "science of delivery", i.e. a science of implementation and execution [23]. We are witnessing a shift from the 'what' and 'why' questions to the 'how' question: how to steer complex policy processes in a way that enhances equity in health [24]. Over recent years, many policymakers in sub-Saharan Africa have opted for exemption policies to lower financial barriers to health care. In West Africa, this has led to a range of user-fee exemptions for vulnerable populations (e.g. children under-5, pregnant women), life-saving interventions (e.g. C-sections) or a combination of both (e.g. malaria treatment for under-5s).

To date, research investigating fee exemption policies by and large remains confined to their (quantitative) impact on utilisation rates, the most frequently used proxy for access to health care [25]. This type of evidence is obviously relevant, but hardly provides insight in how and why exemption policies work (or not). Limited evidence on the mechanisms of success and failure shows mixed results [2631], with two conclusions systematically surfacing: the impact of fee exemptions is highly context-dependent; its understanding requiring in-depth exploration of both intended and unintended effects.

This special issue on fee exemption policies in West Africa couldn't be more timely. In the papers presented in this issue, the authors present results from research conducted by a range of teams led by Valéry Ridde and Jean-Pierre Olivier de Sardan in Mali, Niger and Burkina Faso over the past 5 to 10 years. The question of implementation is central in all the contributions.

Exploring policy implementation requires a certain level of flexibility, adapting and combining research methods in a way that enables the capture of complex social processes. This is precisely what the contributors to this special issue did. They present interesting examples of research endeavours, conducted simultaneously or successively, borrowing from various disciplines: history, sociology, political science, anthropology, and of course public health. The added value of such a blended approach - allowing for in-depth analysis of social, political, economic and cultural dimensions of public policies - cannot be underestimated.

We are confident that this issue will feed into the current debates on how to develop health equity intervention research [32]. More specifically, it will help to improve evaluation methodologies that capture contextual and other critical influences to understand what works to make significant progress towards UHC and how and why it does. Ultimately, such comprehensive knowledge can pave the way for transformative policies [33, 34], a necessary condition for health equity.


  1. Brolan CE, Hill PS: Countdown for health to the post-2015 UN Sustainable Development Goals. Med J Aust. 2015, 202 (6): 289-290.

    Article  PubMed  Google Scholar 

  2. O'Connell T, Rasanathan K, Chopra M: What does universal health coverage mean?. Lancet. 2014, 383 (9913): 277-279.

    Article  PubMed  Google Scholar 

  3. Frenz P, Vega J: Universal health coverage with equity: what we know, don't know and need to know. [Online] Available from:

  4. Kutzin J: Anything goes on the path to universal health coverage?. Bull World Health Organ. 2012, 90 (11): 867-868.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Sen A: Universal healthcare: the affordable dream. 2015, [Online] Available from:

    Google Scholar 

  6. World Health Organisation, The World Bank: Tracking Universal Health Coverage: First Global Monitoring Report. [Online] Available from:

  7. Tangcharoensathien V, Mills A, Palu T: Accelerating health equity: the key role of universal health coverage in the Sustainable Development Goals. BMC Medicine. 2015, 13 (1): 101-

    Article  PubMed  PubMed Central  Google Scholar 

  8. Sen A: Why health equity?. Health Econ. 2002, 11 (8): 659-666.

    Article  PubMed  Google Scholar 

  9. Etienne CF: Achieving universal health coverage is a moral imperative. Lancet. 2014, 385 (9975): 1271-1273.

    Article  PubMed  Google Scholar 

  10. Soors W, Dkhimi F, Criel B: Lack of access to health care for African indigents: a social exclusion perspective. Int J Equity Health. 2013, 12: 91-

    Article  PubMed  PubMed Central  Google Scholar 

  11. Bitran R, Giedion U: Waivers and exemptions for health services in developing countries. Washington

  12. Stierle F, Kaddar M, Tchikaya A, Schmidt-Ehry B: Indigence and access to health care in sub-Saharan Africa. Int J Health Plann Manage. 1999, 14 (2): 81-105.

    Article  CAS  PubMed  Google Scholar 

  13. Lagarde M: The impact of user fees on health service utilization in low- and middle-income countries: how strong is the evidence?. Bull World Health Organ. 2008, 86 (11): 839-848.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Lagarde M, Palmer N: The impact of user fees on access to health services in low- and middle-income countries. Cochrane Database Syst Rev. 2011, 4: CD009094-

    PubMed  Google Scholar 

  15. Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJL: Household catastrophic health expenditure: a multicountry analysis. Lancet. 2003, 362 (9378): 111-117.

    Article  PubMed  Google Scholar 

  16. Dzakpasu S, Powell-Jackson T, Campbell OM: Impact of user fees on maternal health service utilization and related health outcomes: a systematic review. Health Policy Plan. 2014, 29 (2): 137-150.

    Article  PubMed  Google Scholar 

  17. Evans DB, Hsu J, Boerma T: Universal health coverage and universal access. Bull World Health Organ. 2013, 546-546A. 91:

  18. Evans DB, Marten R, Etienne C: Universal health coverage is a development issue. Lancet. 2012, 380 (9485): 864-865.

    Article  PubMed  Google Scholar 

  19. Garrett L, Chowdhury a MR, Pablos-Méndez A: All for universal health coverage. Lancet. 2009, 374 (9697): 1294-1299.

    Article  PubMed  Google Scholar 

  20. World Health Organisation: World Health Report - Health Systems Financing: The path to Universal Coverage. [Online] Available from:

  21. Östlin P, Schrecker T, Sadana R, Bonnefoy J, Gilson L, Hertzman C, et al: Priorities for research on equity and health: towards an equity-focused health research agenda. PLoS Med. 2011, 8: e1001115-

    Article  PubMed  PubMed Central  Google Scholar 

  22. Nicholson D, Yates R, Warburton W, Fontana G: Delivering Universal Health Coverage: A Guide for Policymakers. [Online] Available from:

  23. Nicholson D: Universal health coverage: reaching a consensus. Lancet. 2015, 385 (9971): 838-

    Article  PubMed  Google Scholar 

  24. Horton R, Das P: Universal health coverage: not why, what, or when--but how?. Lancet. 2014, 385 (9974): 1156-1157.

    Article  PubMed  Google Scholar 

  25. Samson M, van Katwyk S, Fröling M, Ndoro R: Methods of Measuring the Impacts of Social Policy in Political, Economic and Social Dimensions. [Online] Available from:

  26. Kanchebe Derbile E, van der Geest S: Repackaging exemptions under National Health Insurance in Ghana: how can access to care for the poor be improved?. Health Policy Plan. 2013, 28 (6): 586-595.

    Article  PubMed  Google Scholar 

  27. Witter S, Arhinful DK, Kusi A, Zakariah-Akoto S: The experience of Ghana in implementing a user fee exemption policy to provide free delivery care. Reprod Health Matters. 2007, 15 (30): 61-71.

    Article  PubMed  Google Scholar 

  28. Witter S, Adjei S, Armar-Klemesu M, Graham W: Providing free maternal health care: ten lessons from an evaluation of the national delivery exemption policy in Ghana. Glob Health Action. 2009, 1-5. 2

  29. El-Khoury M, Hatt L, Gandaho T: User fee exemptions and equity in access to caesarean sections: an analysis of patient survey data in Mali. Int J Equity Health. 2012, 11: 49-

    Article  PubMed  PubMed Central  Google Scholar 

  30. Agha S: Changes in the proportion of facility-based deliveries and related maternal health services among the poor in rural Jhang, Pakistan: results from a demand-side financing intervention. Int J Equity Health. 2011, 10: 57-

    Article  PubMed  PubMed Central  Google Scholar 

  31. Ridde V, Queuille L, Kafando Y, Robert E: Transversal analysis of public policies on user fees exemptions in six West African countries. BMC Health Serv Res. 2012, 12: 409-

    Article  PubMed  PubMed Central  Google Scholar 

  32. Commission on Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health. [Online] Available from:

  33. Devereux S, Sabates-Wheeler R: Transformative social protection. [Online] Available from:

  34. Michielsen J, Meulemans H, Soors W, Ndiaye P, Devadasan N, De Herdt T, et al: Social protection in health: the need for a transformative dimension. Trop Med Int Health. 2010, 15 (6): 654-658.

    Article  PubMed  Google Scholar 

Download references


This article has been published as part of BMC Health Services Research Volume 15 Supplement 3, 2015: User Fee Exemption Policies. The full contents of the supplement are available online at

Author information

Authors and Affiliations


Rights and permissions

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Dkhimi, F., Soors, W. & Criel, B. Foreword. BMC Health Serv Res 15 (Suppl 3), I1 (2015).

Download citation

  • Published:

  • DOI: