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Do user fees increase or decrease access to basic services?

Shanta Devarajan's picture

In a recent paper, Alaka Holla and Michael Kremer appear to resolve this controversial issue by surveying findings of a series of randomized evaluations. They conclude that user fees in health and education do reduce access. On page 33 of their 45-page paper, they mention that they have not looked at the impact of user fees on provider incentives. Yet this may be the crux of the debate. Everyone would be in favor of lowering or eliminating user fees if we could be sure that poor people would receive the services. But for various reasons having to do with government failures, the subsidies needed to ensure that these services are provided either don’t arrive or don’t provide sufficient incentives for providers to even show up for work. Poor people, desperate to get their children educated or treated in clinics, pay user fees out of necessity. We should be working on overcoming these government failures so that lowering user fees will, in fact, lead to better access and quality services.   

Comments

Submitted by Prince Emeka Obasi on
We publish a business newspaper in Nigeria, Business Hallmark... I have followed your blog with interest. Your article, "A fiscal stimulus for Africa in particular made an interesting reading. We will appreciate it if you could write for us as a colunmist weekly. We would willingly pay an honorarium for your service. And more importantly millions of Nigerian readers will be enriched by your experience.

Submitted by Emmy Wasirwa on
It is true "user fees decrease access to basic services". We all understand that about 90% of Africans live on less than $1 a day and it is common knowledge that the same population rely on substance farming. It is also well documented that 88% of most African GDP rely on agriculture and needless to say most of the people who can pay most of these services are unemployed or those who are employed their income can not support them to access such services. For example a study conducted by Americans in Uganda in the last half of 2007 found that 75% of Ugandans dont have access to appropriate health care and there was a high percentage of pupil drop out in schools which requested to contribute towards their primary education. With all these it is common knolwedge that user fees have impact on the access of basic services for people in Africa. Therefore there is a need to investigate other ways of improving access to services or in other words investigate ways of putting money in peoples pockets to enable them pay for such services.

Submitted by Milissao Nuvunga on
I got a bit confused by your entry on user fees and access to basic services. If user fees have been found to reduce access, why go along with them? The basic idea of user fees, if I am not mistaken, was actually to increase the incentives for users to hold service providers accountable. The decrease in access means the strategy is not working. I haven't read the paper you base your comments on, but it seems you argue for user fees as the only feasible strategy even though this strategy leads to a worse outcome for the poor than having free access. Why have user fees if they tax the poor AND decrease access to basic services? It seems you place more emphasis on a theoretical modelling of democratic accountability than on access to health and education.

Submitted by Valence on
Hello. In my honest opinion user fees are very important in any field of service including education and health care. People working in the social sector should be funded not exclusively from the state budget. Also, this can condition (but not guarantee) the quality of services. As for the poor, they should be subsidized by the state and have the benefits, up to providing basic services to them for free.

Submitted by Brent on
Education is very important This is why I got my degree and i made sure if everything is honest and truthful The population is getting sick people are dying in silance without any care on the responsibility of Health Education

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