Published on Africa Can End Poverty

Do user fees increase or decrease access to basic services?

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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.   


Shanta Devarajan

Teaching Professor of the Practice Chair, International Development Concentration, Georgetown University

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