[stop-imf] RESULTS fact sheet: World Bank and user fees on primary health and education

Robert Weissman rob@essential.org
Thu, 16 Aug 2001 23:16:42 -0400 (EDT) 

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RESULTS

For More Information:
Joanne Carter, RESULTS (202)783-7100
carter@action.org
Rick Rowden, RESULTS Ed. Fund
rowden@action.org

USER FEES ON PRIMARY HEALTH AND EDUCATION

In Zambia, a researcher witnessed the arrival of a
14 year old boy at a hospital, suffering from
acute malaria. His parents were unable to pay the
registration fee of ZK300 (equivalent to 33 cents
US) and the boy was turned away. The report added
that, "within two hours the boy was brought back
dead."
UNICEF, Jan. 2000, Absorbing Social Shocks,
Protecting Children and Reducing Poverty

WHAT ARE USER FEES? User fees are fees imposed for
health care or education (e.g. school fees, fees
for textbooks; fees for using a health clinic).
Often these services were previously provided for
free or at nominal cost.  These user fees have
been aggressively promoted by the World Bank and
International Monetary Fund, and are often a
condition for new loans and debt relief.
Currently, user fees have begun to be charged for
access to safe and clean water supplies, and the
effects of the new policies are coming under
increased scrutiny.

THE HUMAN IMPACTS OF USER FEES:

Zimbabwe:  UNICEF reported in 1993 that the
quality of health services had fallen by 30% since
1990, twice as many women were dying in childbirth
in Harare hospital as before 1990 and that fewer
people were visiting clinics and hospitals because
they could not afford hospital fees.  Attendance
at one clinic went from 1200 in 3/91 to 450 in
12/91 following imposition of fees.   In her book,
Faith and Credit, author Susan George quoted a
British charity which reported girls going into
prostitution in order to pay school fees.

Ghana: The Living Standards Survey for 1992-1993
found 65% of rural families said they could not
afford to send children to school consistently.
Furthermore, 77% of street children in the capital
city of Accra dropped out of school because of
inability to pay fees.

Malawi: When Malawi eliminated a modest school fee
in 1994, primary enrollment soared by 50% almost
overnight-from 1.9 to 2.9 million pupils.

Uganda: When Uganda recently eliminated school
fees in 1998, the primary school enrollment rate
climbed from 50% to 90%.

Kenya:  The introduction of fees for patients of
Nairobi's Special Treatment Clinic for Sexually
Transmitted Diseases (STDs) resulted in a decrease
in attendance of 40% for men and 65% for women
over a nine-month period.  Failure to treat STDs
can significantly increase the likelihood of
transmission of HIV/AIDS.

Tanzania: Primary school fees were introduced for
the first time in 1999-and even included as part
of the HIPC debt relief agreement.  According to
the Evangelical Lutheran Church of Tanzania, less
than half of the projected revenue from school
fees has been collected-because families simply
cannot pay. All that user fees have succeeded in
doing is reducing the access of the poor to
school.


WORLD BANK AND UNICEF ON USER FEES AND FAILURE TO
EXEMPT THE POOR:

=B7  The World Bank's Operations Evaluation
Department (OED) reported in a 1998 Seminar Report
and that: "about 40% of projects in the Bank's HNP
(health, nutrition and population) portfolio and
nearly 75% of projects in sub-Saharan Africa
included the establishment or expansion of user
fees.  Project documents typically assert that the
poor would be protected from the impact of these
fees, but include few if any detail about how this
is to be done. Nor do project evaluation reports
provide much evidence about how well the poor have
in fact been exempted."

To look further into this, the OED commissioned a
set of country case studies and reported: "In
Zimbabwe, the government included a system of
waivers for the poor when it introduced user fees
in the early 1990s...fewer than 20% of the
eligible poor ended up receiving waivers.  The
government then switched to a form of
characteristic targeting, by eliminating fees for
infant and child health services in rural clinics.
This appears to have worked considerably
better..."  "In Mali, the Bank had supported
introduction of community-managed health centers,
whose recurrent costs were covered primarily
through service fees.  Communities were empowered
to grant fee waivers to the indigent.  But in
their site visits, OED team members found no
examples where waivers had actually been granted."

=B7 The 2000 World Bank World Development Report
(WDR) on Poverty states: "few developing
countries, however, have successfully implemented
price discrimination in health services through
sliding scale fees. In most African countries such
exemptions tend to benefit wealthier groups (such
as civil servants).  In Ghana's Volta Region in
1995 less than 1% of patients were exempt from
health user fees and 71% of exemptions went to
health service staff."

The WDR on Poverty also acknowledges that health
and education fees lock the poor out, and that
"free primary education for poor people is
critical for expanding their human assets,
especially for girls."

=B7 According to a January 2000 UNICEF paper
[Absorbing Social Shocks, Protecting Children and
Reducing Poverty], "remarkably little evidence
exists on the effectiveness of exemption systems
[for user fees]." UNICEF cites a study which found
that exemption schemes for health in sub-Saharan
Africa are not only rare, but they are also
implemented in informal and ad hoc ways.

CONGRESS ACTED TO STOP USER FEES ON BASIC
SERVICES:

In a historic move, the U.S. Congress passed a law
last year that requires the U.S. to oppose any
World Bank, IMF, or other multilateral development
bank loan which includes user fees for basic
health or education services. However, the U.S.
Treasury Department has failed to comply with the
law, and still supports user fees on health care
at the IMF and the World Bank (see: Center for
Economic and Policy Research, "Is U.S. Treasury
Above the Law? Failure of the U.S. Treasury
Department to Comply With the Congressional
Prohibition on U.S. Support for User Fees on
Primary Education and Health Care at the IMF and
the World Bank", www.cepr.net)

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------=_NextPart_000_0063_01C124AC.7C48B880--