[stop-imf] Elimination of User Fees brings big increase in clinic utilization rates in Uganda

[Robert Weissman]

Elimination of User Fees brings big increase in clinic utilization rates in
Uganda

Rick Rowden
Researcher
RESULTS Educational Fund
Washington, DC



Buried in the depths of Uganda's official Ministry of Health Annual
Performance Report for 2001/02 (page 61) are some startling statistics about
the results of Uganda's decision to go against World Bank advice and abolish
health user fees: in one year there has been a spectacular increase in
utilization of services totaling a 40% increase in attendance for
outpatients and an increase from 48 to 63% for DPT3 immunizations.

"This is a massive good news story which needs to get out," says Mr. Robert
Yates, a Ugandan Civil Servant who works with the Health Ministry.  Although
the in-country representatives of the International Monetary Fund and World
Bank are "not exactly singing this from the roof tops," President Museveni
is quite pleased with the outcome.  Museveni, who went against World Bank
policy advice on the issue and joined Tanzania and other countries in
unilaterally dropping the much-maligned "user fees", went out of his way to
criticize the World Bank for "imposing user fees" (his words) at the recent
Commonwealth Health Ministers' meeting in Entebbe and was now proudly
showing the results of having eliminated them.  One key result is that
millions of Ugandans are now accessing health care services that the fees
had blocked them from receiving.

In the course of in-depth surveys taken as part of the Uganda Participatory
Poverty Assessment Programme (UPPAP) in 2000/1, President Museveni became
aware of just how tremendously unpopular the user fees were, and sought to
eliminate them despite World Bank pressure to retain the fees.

"User fees" can best be understood as a symptom of the larger budget
cuts in
health and education spending that had long come as a result of overall
budget austerity insisted upon by the IMF.  The IMF is very clear that it
never told governments where to cut their budgets, only to reduce the
overall budgets to be within certain parameters.  It is the following budget
battles between
line ministries that always led to the politically weakest ministries
getting the short end of the stick.  After many years of chronic
under-funding, the World Bank began suggesting in the late 1980s that health
and education ministries charge user fees at clinics and schools as a good
way to make up for reduced health & education budgets.

However, 15 years of mounting evidence by UNICEF and others showed the fees
were keeping poor people from accessing health care or primary school.  This
research led many health and education advocates and civil society groups,
including the US lobby group, RESULTS, to successfully get the U.S. Congress
to include language in the 2001 foreign aid appropriations bill report 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, and to report to Congress within 10 days should any loan or other
agreement be approved that includes such user fees.   The US legislation had
a significant impact inside the World Bank, which relented under pressure
and officially reversed its user fees policy in September 2001.  The Bank's
new policy is quite clear on its new opposition to primary school user fees,
but is much more ambiguous on the need do away with health user fees.
Despite the Bank's official policy switch, today many other developing
countries continue to see the fees as a substitute for larger budgets
and as
a way of coping with IMF budget austerity.

This Ugandan good news story takes on added significance in advance of the
World Bank's upcoming World Development Report 2004, in which the Bank will
be consistent with its efforts to argue against increasing support for
public health services - even suggesting that it is not worth investing more
money in them.  The upcoming WDR is an attempt to rebut the important
conclusions reached in 2001 by the World Health Organization's report of the
Commission on Macroeconomics and Health.   This report turned neoliberal and
free market logic on its head: for years the IMF and World Bank have been
telling governments to cut state spending in an effort to decrease budget
deficits, keep inflation low and raise overall economic growth rates; and
only after economic growth rates materialize could governments then increase
spending on health & education.  Yet the WHO's Commission on Macroeconomics
& Health concluded the very opposite: vast increases in public health and
education spending now will lay the social foundation necessary for higher
economic growth rates in the future.

Fighting the spread of HIV/AIDS, increasing literacy rates and improving
overall prospects for real development will require eliminating the harmful
and regressive "user fees" so that, as this vital Ugandan evidence suggests,
poor people can more easily access critical health services.