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User fees and worst off: it’s time to find a solution
  1. Valéry Ridde
  1. Correspondence to:
 Valéry Ridde
 International Health Unit, Medical Faculty, Université de Montréal, 3875 rue Saint-Urbain, Montréal, QC Canada, H2W 1V1; valery.ridde{at}

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Rooted in market oriented approaches to health financing, user fees have been recommended for two decades by international agencies and aid donors as a mechanism for mobilising new resources and rationalising service delivery. Many developing countries are still relying on user fees. No credit was permitted in a health centre in Haïti (January 2005, in French and Creole: “no credit for you today, perhaps tomorrow, thank you”). In contrast with the claims of user fees proponents, such financing methods have excluded vulnerable populations from basic health service, with damaging implications for equity.1 Even the World Bank is stating now that they “did not support user fees for basic health services for poor people”.2 Removing user fees for primary care is necessary but it’s not enough3 even if the case of Uganda seems interesting in terms of equity.4 Prepayment and voluntary insurance schemes are not able to protect the worst off and most of the exemption systems have failed to protect the poorest. We still know so little about health financing to promote access in low income settings.5 In the context of user fees and cost recovery schemes, some pilot projects are emerging in Cambodia (Equity Fund), Mali (Medical Assistance Fund), and Burkina Faso (Community exemptions schemes), but more research is needed to provide evidence to decision makers to implement more health equity policies.

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This picture was taken in Haïti during an evaluation mission for the NGO “Fondation Terre des homes” and funded by ECHO.