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:
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."
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)
