Key messages
Our study shows that promoting user fees as a way of financing health systems of LMICs is no longer the trend. There is indeed a consensus among GHAs who take a stand, at least from a rhetorical point of view, in favor of avoiding user fees at the point of delivery. User fees are deemed not only as the most inequitable means of health system financing, but also as a major barrier to access to care. However, the consensus is less obvious on the action. Most GHAs suggest abolishing user fees or establishing free access to health services. Several others, including intergovernmental organizations, avoid mentioning free healthcare; rather, they emphasize the need to find alternative mechanisms of financial protection, such as social protection [
64,
79] or pre-payment mechanisms [
63,
65]. As shown in the Additional file
2, beneficiaries of these measures are often identified as the most vulnerable and the poorest and coincide with the target beneficiaries of the health Millennium Development Goals (mothers, children under 5, people living with HIV/AIDS). This is consistent with the statements made by some GHAs that user fees hinder the achievement of the Millennium Development Goals by slowing access to health care.
Our study also shows that international non-governmental organizations are more likely to take a stand than other GHAs. Most [
80‐
83] have an advocacy mission, which leads them to take sides on diverse development or humanitarian issues, such as access to care. They are also direct witnesses of the problem of access to care for vulnerable populations. In contrast, few government agencies take a stand, probably because of their position in the global agora. Indeed, government agencies are responsible for implementing the foreign policy of their country, whose first aim is to defend its national interests on the international scene [
84,
85]. Each undertaking is part of a complex diplomatic logic [
85], especially as some are among the largest donors in the field of health.
History of changes
While some international non-governmental organizations have been defending the principle of free care for a long time, this is not the case of government agencies and intergovernmental organizations that have sometimes contributed - directly or indirectly - to the implementation of user fees. Indeed, UNICEF and WHO influenced the Bamako Initiative, which promoted user fees in LMICs. At that time, the World Bank was becoming influential in the health sector, transforming power relations on the international health scene [
86‐
88]. Although it was not involved in the development of the Bamako Initiative, it pursued structural adjustment programs in developing countries since the early 1980s that aimed to reduce public spending in the social sectors. These programs contributed to the expansion of the Bamako Initiative. The diversification and expansion of the World Bank to the health sector influenced the nature of health financing reforms, leading to the “
fabrication of a consensus”, as put by Serre and Pierru [
88].
This movement was part of a broader discussion about health system financing in Western countries and in LMICs, which started in the early 1990s. In this way, “[…]
the propagation of HCF (
health care financing)
has been […]
shaped by the building of a consensus across different institutions and national settings,
defining the '
problem'
of HCF and potential solutions” [
87]. Through its financial strength and technical expertise, the World Bank became the leader on the global health scene [
89], defining new norms and rules for international cooperation organizations, academic institutions and policy makers of LMICs who were dependent on international aid [
86]. A paradigm was born and contributed to influence the vast majority of health care financing reforms in LMICs, particularly on the African continent.
The discourse on health care financing is characterized by a change in the stance of major GHAs, including intergovernmental organizations. Indeed, between the stance of the World Bank in 1987 and its stance twenty years later [
35], the dominant principle of user-pays has fizzled out. The recent speech by its president Jim Yong Kim at the World Health Assembly [
90] in May 2013 gives effect to this change. He claimed there: “
Anyone who has provided health care to poor people knows that even tiny out-
of-
pocket charges can drastically reduce their use of needed services.
This is both unjust and unnecessary.”
Is this change
incremental or
fundamental? As opposed to incremental change, fundamental or paradigmatic change is “
a fundamentally new direction […],
also understood as signifying the emergence of a new paradigm or way of thinking about a policy issue.” [
91]. If our study shows the existence of a consensus, it also shows that some intergovernmental organizations and working groups and transnational networks have a nuanced stance and abstain, in particular, from promoting the abolition of user fees. They have a moderate discourse in which one perceives a tension between the desire to support the abolition of direct payments, for the sake of fairness and social justice, and the need to provide solutions to ensure the sustainability of health care financing. The same tension exists in the discourse of health staff, particularly in Mali, who admit that user fees are a barrier to access to health care for the poor, while remaining cautious about possible alternatives [
92]. Therefore, the consensus may be more about the need to find alternative ways to finance equitable health systems, such as universal health coverage.
In addition, we may legitimately ask whether certain intergovernmental organizations’ statements are not empty statements of principle. Indeed, speech façades, that use the vocabulary promoted by civil society in particular, are no stranger to international health policy [
93]. For example, the goal of fairness that is shared by all GHAs and that helps justify their stance is never defined. The more systematic presence of this objective in the discourse of GHAs is certainly a step towards the establishment of common values within the international community [
94]. Yet, the risk that it becomes a slogan for some GHAs is present.
Evidence and networks: the drivers of change
The change of GHAs’ stance can be explained by the coexistence of several factors. We believe that the production and dissemination of scientific evidence on user fees and the influence of some networks of actors in global health have contributed to this change.
Since the 1990s, the evidence-based approach has gained interest, particularly in the area of political decision-making [
95]. This approach aims to encourage policy-makers to take scientific evidence into consideration when developing new policies. International organizations have undertaken to contribute to the production of knowledge, either through their own publications [
88,
95], or through the financing of research in the academic world [
87]. This evidence could allow some intergovernmental organizations to justify particular discourses and promote specific policies, from a strategic and argumentative perspective [
88].
Given the considerable challenge of health care financing reforms, and in order to inform policy makers and the public about the effects of these reforms, many researchers have focused on the impact of user fees on utilization of health services by populations [
15]. For their part, INGOs, especially Save the Children, have capitalized on their field experience to produce information on the effects of user fees on access to care for vulnerable populations [
48,
96]. Despite the methodological limitations of these studies, the results mostly demonstrated a negative impact of user fees on access to health care for the poor [
11]. This abundance of scientific evidence and field experience may have contributed to change the position of GHAs. It also strengthened the committed discourse of INGOs, as shown by the use of scientific literature in their documents. If evidence could not be the single factor changing the position of intergovernmental organizations, it certainly contributed to the already strong debate between supporters and critics of user fees, while casting doubt on these cost recovery policies in the minds of LMICs policy makers.
Knowledge can contribute to political change, but only as the instrument of change that actors must use. These actors, whether they are individual or collective, have beliefs and values. They have goals they seek to achieve through the mobilization of resources and they are constrained by rules and institutions [
97]. Advocacy networks offer an interesting perspective for understanding the involvement of different actors in policy changes over long periods [
98]. These networks consist of “
persons holding a variety of positions (
elected officials,
interest group leaders,
researchers)
who share a particular belief system –
i.
e.,
a set of basic values,
causal reasoning,
and perceptions of problems –
and who show a significant degree of coordinated activity over time”. In this perspective, ideas have an important role in the process of change and elaboration of public policy at the national level. Two types of networks seem to have played a role in the political change of health care financing in LMICs: global policy networks, particularly transnational political elite [
87], and transnational advocacy networks [
99].
Lee et Goodman [
87] trace the path of health care financing reforms and show the role of global policy networks in building consensus: “
This consensus has been achieved through a range of research and training initiatives,
project funding,
the career movement of individuals,
and other forms of collaborative work across higher-
and lower-
income countries,
health economics and public health,
and public and private sectors." The authors highlight the "
transatlantic divide” between American schools of thought, which are in favor of user fees, and European schools, which are rather unfavorable to user fees. The scope of this study ends in the 2000s and offers a historical perspective that is necessary to understand how the terms of the debate on user fees in LMICs evolved. For further analysis, we could focus on elements recognized as having fostered the emergence of a consensus, including how European schools of thought have gained legitimacy, to the point of participating in reversing dominant positions.
Transnational advocacy networks [
99] differ from advocacy networks not only by their transnational character, but also by their activism. A transnational advocacy network “
includes those relevant actors working internationally on an issue,
who are bound together by shared values,
a common discourse,
and dense exchanges of information and services.” Among these networks, INGOs play a central role, as they are able to initiate actions and put pressure on key international stakeholders. Indeed, INGOs “
participate in the agenda setting of international issues,
in the decision-
making process and in the implementation of international action programs” [
100]. Several INGOs have published a large number of reports showing the negative effects of user fees on access to care for the poor, while putting pressure on their government and / or intergovernmental organizations to make them take a clear position in favor of free care at the point of delivery. Transnational advocacy networks have several levers to influence policy decision-making [
99]: “
information politics” which is the capacity to quickly mobilize politically relevant information; “
symbolic politics” which is the ability to use symbols or striking stories to give meaning to action; “
leverage politics” which is the ability to solicit more powerful stakeholders to influence a situation; “
accountability politics” which is the ability to compel actors to comply with their declaration of intent. We think that the study of these tactics would allow a better understanding of the influence that these actors have had in changing the stance of intergovernmental organizations and government agencies with respect to user fees in LMICs.
Beyond these two drivers of change, our study suggests a third driver: the LMICs themselves. We note that the publication of documents in which GHAs take a stand in favor of free care or the abolition of user fees increases between 2008 and 2010. It is during this period that influential stakeholders such as the WHO, the European Commission, the G8 and several working groups and transnational networks take a stand in the debate. However, these documents follow the decision of several LMICs to implement user fee exemption policies. Indeed, Ghana and Burkina Faso opted for exemption policies for maternal health in 2003, followed in 2005 by Niger, Mali and Senegal [
19]. This suggests that most GHAs may have felt they had to take a stand with regard to the policies initiated by LMICs. However, the multiplicity of exemption measures since 2009, particularly in West Africa, suggests that the stance of GHAs has in turn prompted other LMICs such as Côte d'Ivoire, Togo and Sierra Leone to implement exemption policies.
From words to deeds
Whatever the nature of the change that is taking place on the international health scene, the stance of GHAs alone is ineffective in improving the health of populations. Even if “
change may be symbolic before being concrete due to the performative dimension of political discourse” [
100], it must be transformed into action to last. The first to take action were international non-governmental organizations, including MSF and MDM. Their documents show their experiences in implementing free health care at the local level. These experiences provided them with arguments for their lobby campaigns. More recently, intergovernmental organizations have pressured governments of LMICs to introduce user fee exemption measures. As an example, in Burkina Faso, the World Bank has supported the implementation of the subsidy for emergency obstetric and neonatal care [
101]. In Niger, the Bank has subordinated loans to the introduction of free health care for children under 5 [
102]. However, the Bank’s conditions were not followed by technical or financial support. In Niger, it has not provided the necessary financial support to ensure the smooth functioning of the exemption measures it advocated. This has forced the country to turn to other donors, such as the French cooperation [
102] which allowed a part of its aid to be used to fund free care for children under 5. The limits of their actions could explain why intergovernmental organizations tend not to mention free care or exemption policies as possible solutions, and merely highlight the inequitable nature of user fees.
These examples illustrate the difficulties faced by LMICs to implementing user fee exemption policies, without the support of donors. Indeed, although many exemption policies were implemented in several sub-Saharan African countries, their outcomes in terms of service utilization were marred by problems of implementation. A lack of preparation, both operational and financial, has been highlighted in many studies [
18,
103]. A major repercussion was the return of illegal user fees [
104‐
106], which may counteract the expected policy effects. Furthermore, exemption policies’ sustainability is far from assured [
107], and out-of-pocket payments remain an issue for those who do not benefit from these policies or have to pay for transportation, medicine, etc. [
66]. Thus, although they have generally shown their potential to improve health services utilization [
108‐
110], user fee exemption policies are rarely promoted as a way to ensure equitable access to healthcare. However they are increasingly seen as a step towards universal health coverage [
20,
107,
111]. In this context, the debate now seems to be more about the most effective and equitable mechanisms to achieve universal health coverage in LMICs.
Limits
Although we conducted the study so as to limit bias, including interpretation bias, our work has some limitations that are inherent to the research design. First, because we used only secondary data, we limited our analysis to the official and public discourse of major stakeholders. However, as shown in the case of Niger, where France supported the user fee exemption policy, the absence of documents addressing the issue of user fees by some GHAs does not mean that there are no positions taken on “the ground”. Similarly, the financial or technical support by a GHA for a national user fee exemption policy or a local free care program does not necessarily mean that it takes a stand against health user fees or for universal free care. Such actions may be motivated by contextual considerations that are political, social or health-related.
In addition, it is possible that certain documents were not found, a major challenge being to ensure the completeness of the data collection strategy. We recall in this respect that the documents marked “the views expressed in this paper are solely those of the author” and similar were excluded. It is also possible that other GHAs not included in our initial sample expressed opinions on the issue of user fees. However, we could not trace their presence in the debate. Indeed, the multiplicity of stakeholders makes it difficult to ensure their full representation. Moreover, the data collection strategy ended in mid-2011; other documents may have been published since and state, specify or modify the stance of some GHAs. Ensuring that findings are up-to-date can be challenging when dealing with global policy issues that are very contemporary and are under close scrutiny.
Finally, the objective of this study was to identify and analyze the public position statements of GHAs in the debate on health user fees. It would have been particularly interesting to understand the evolution of the change in the stances of GHAs in this debate and analyze how it relates to the international debate on healthcare financing. However this is beyond the scope of our study.