User fees are widely regarded as one of the main obstacles to increasing poor people’s access to health care in developing countries and, in doing so, promoting more inclusive forms of development.
During the 1980s and early 1990s, a number of developing country governments introduced formal fees for health services in an attempt to generate much-needed resources for public health facilities. But, while the World Bank argued that such fees would not impair poor people’s access to health services, numerous studies suggest that they had precisely that effect (James et al 2006; Yates 2009). Some governments subsequently sought to deal with this problem by declaring that poor patients should be exempted from paying fees, a move that proved ineffective because it meant that these patients became a financial loss for public health facilities, in turn encouraging them to either withhold their services or demand illegal payments. Accordingly, a new consensus has emerged against user fees, both legal and illegal, and their removal is back on the global development agenda.