Economic contestation over user fees in low-resourced healthcare systems: A literature review

  • Vincent Pagiwa | Okavango Research Institute, University of Botswana, Maun, Botswana.


This paper reviewed the literature on economic theory and assumptions that provide the rationale for using a price system to finance health care services in developing countries. The primary case in favor of a system of user fees for financing healthcare in these countries lies in allocative efficiency results to be achieved through a price system. The assumption being that, the price system signals to consumers what they must pay for health care services hence giving them an incentive to utilize those services well. However, this assumes perfect markets, where prices reflect the true marginal benefits of consuming healthcare goods and the marginal cost of their production. All equity concerns being addressed through price discrimination, a system of user fees can then allocate health care resources efficiently. Although the application of user fees in the health sector is justified by the perfect markets, there are concerns that a perfect market is less likely to be the case in health sector. Therefore, it will not be a viable way to rely on the price system to allocate resources to the population when markets of any healthcare goods and services are not available or are imperfect. Information asymmetry and uncertainty are the major obstacles to a proper function of a price system in healthcare service provision. Due to the inelastic nature of the demand for healthcare, charging fees for healthcare services can pose hard financial catastrophes to poor and lead into poverty. This suggests the need to establish healthfinancing policies that would facilitate the creation of new markets or which can improve the performance of existing ones in developing countries.



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Nolan B, Turbat V. Cost Recovery in Public Health Services in Sub-Saharan Africa. The World Bank; 1995: p.114.

Dercon S, Ruttens C. Cost recovery in health care in Africa: a review of the principles and the effects on the poor. Word Bank Institute Resources 1998 BVO/98.2

Akin J, Birdsall N, de Ferranti D. Financing Health Services in Developing Countries. World Bank Publications; 1987: p. 99.

Schieber GJ. Innovations in health care financing. World Bank Publications; 1997: p. 266.

Shaw RP, Griffin,CC. Cost Sharing: Towards Sustainable Health Care in Sub-Saharan Africa. Africa Region Findings & Good Practice Infobriefs; No. 63. Washington, DC: World Bank; 1996.

Ridde V, Morestin F. A scoping review of the literature on the abolition of user fees in health care services in Africa. Health Policy Plan 2011;26:1–11.

Opwora A, Waweru E, Toda M, et al. Implementation of patient charges at primary care facilities in Kenya: implications of low adherence to user fee policy for users and facility revenue. Health Policy Plan 2015;30:508–17.

Global Health Observatory. Out-of-pocket expenditure as percentage of current health expenditure (CHE) (%) - Data by World Bank income group. World Health Organization; 2020.

Cook DJ, Mulrow CD, Haynes RB. Systematic reviews: synthesis of best evidence for clinical decisions. Ann Intern Med 1997;126:376–80.

McGrath J, Saha S, Welham J, et al. A systematic review of the incidence of schizophrenia: the distribution of rates and the influence of sex, urbanicity, migrant status and methodology. BMC Med 2004;2:13.

Linares-Espinós E, Hernández V, Domínguez-Escrig JL, et al. Methodology of a systematic review. Actas Urol Esp 2018;42:499–506.

Mwabu G. User Charges for Health Care: A Review of the Underlying Theory and Assumptions. 1997. UNU: 5218.

Araoyinbo I, Ataguba J. User fees in Africa: from theory and evidence, what next? An essay submitted to the African Health Economics and Policy Association. Alliance for Health Policy and System Research 2008. Available form:

Glied S, Smith PC. The Oxford Handbook of Health Economics. Oxford University Press; 2011.

Kolstad JT, Chernew ME. Quality and consumer decision making in the market for health insurance and health care services. Med Care Res Rev 2009;66:28S-52S.

Dupas P. Global health systems: pricing and user fees. Prepared for the Elsevier Encyclopedia of Health Economics, 2012. Accessed 17.3.2013.

Madore O. The health care system in Canada: effectiveness and efficiency. Ottawa: Library of Parliament, Research Branch; 1993: p. 15.

Schokkaert E, de Voorde CV. User Charges. The Oxford Handbook of Health Economics. Oxford Publishers; 2011.

Thaler R. Toward a positive theory of consumer choice. J Econ Behavior Organization 1980;1:39–60.

Roth S, Robbert T, Straus L. On the sunk-cost effect in economic decision-making: a meta-analytic review. Bus Res 2015;8:99–138.

Arkes HR, Blumer C. The psychology of sunk cost. Organizational Behavior and Human Decision Processes 1985;35:124–40.

Cunha MC, Caldieraro F. Sunk-Cost Effects on Purely Behavioral Investments. Cognitive Sci 2009;33:105–13.

Aron-Dine A, Einav L, Finkelstein A, Cullen M. Moral Hazard in Health Insurance: Do Dynamic Incentives Matter? The Review of Economics and Statistics 2015;97:725–41.

Baicker K, Mullainathan S, Schwartzstein J. Behavioral Hazard in Health Insurance. Q J Econ 2015;130:1623–67.

Bajari P, Dalton C, Hong H, Khwaja A. Moral hazard, adverse selection, and health expenditures: A semiparametric analysis. The RAND J Econ 2014;45:747–63.

Geyman JP. Moral hazard and consumer-driven health care: a fundamentally flawed concept. Int J Health Serv 2007;37:333–51.

World Bank. World Development Report 1993:Investing in Health, Volume 1. World Bank Publications; 1993: p. 346.

Griffin CC. User charges for health care in principle and practice. International Bank for Reconstruction and Development, World Bank; 1988.

McPake B, Normand C, Smith S, Nolan A. Health economics: an international perspective. Routledge; 2020

Pendzialek JB, Simic D, Stock S. Differences in price elasticities of demand for health insurance: a systematic review. Eur J Health Econ 2016;17:5–21.

Zhou Z, Su Y, Gao J, et al. New estimates of elasticity of demand for healthcare in rural China. Health Policy 2011;103:255–65.

Ringel JS, Hosek SD, Vollaard BA, Mahnovski S. The Elasticity of Demand for Health Care: A Review of the Literature and Its Application to the Military Health System. RAND Corporation; 2002. No. MR-1355-OSD.

Ellis RP, Martins B, Zhu W. Health care demand elasticities by type of service. J Health Econ 2017;55:232–43.

Fox W, Edmiston K. User Charge Financing of Urban Public Services in Africa. International Center for Public Policy, Andrew Young School of Policy Studies, Georgia State University; 2000. Report No.: paper0004.

Onarheim KH, Sisay MM, Gizaw M, et al. Selling my sheep to pay for medicines – household priorities and coping strategies in a setting without universal health coverage. BMC Health Serv Res 2018;18:153.

Shaw RP, Ainsworth M. Financing health services through user fees and insurance. World Bank Publications (World Bank Discussion Papers); 1996: p. 254.

John EU. The Impacts of User Fees on Health Services in Sub-Saharan African Countries: A Critical Analysis of the Evidence. Am J Public Health Res 2013;1:196–202.

Roberts J. Primary care: core values Primary care in an imperfect market. BMJ 1998;317:186–9.

Vaithianathan R. Health insurance and imperfect competition in the health care market. J Health Econ 2006;25:1193–202.

Arrow KJ. Uncertainty and the welfare economics of medical care. 1963. Bull World Health Organ 2004;82:141–9.

Donaldson C, Gerard K. Market Failure in Health Care. In: Donaldson C, Gerard K, editors. Economics of Health Care Financing: The Visible Hand. London: Macmillan Education UK; 1993. p. 26–48.

Nguyen H. The principal-agent problems in health care: evidence from prescribing patterns of private providers in Vietnam. Health Policy Plan 2011;26:i53–62.

Novotny TE, Zhao F. Consumption and production waste: another externality of tobacco use. Tob Control 1999;8:75–80.

Chen F, Toxvaerd F. The economics of vaccination. J Theor Biol 2014;363:105–17.

England S, Kaddar M, Nigam A, Pinto M, Organization WH. Practice and policies on user fees for immunization in developing countries WHO. 2001. Available from:

Gilson L. The lessons of user fee experience in Africa. Health Policy Plan 1997;12:273–85.

Munge K, Briggs AH. The progressivity of health-care financing in Kenya. Health Policy Plan 2014;29:912–20.

Steinhardt LC, Aman I, Pakzad I, Kumar B, Singh LP, Peters DH. Removing user fees for basic health services: a pilot study and national roll-out in Afghanistan. Health Policy Plan 2011;26:ii92–103.

Gilson L, Russell S, Buse K. The political economy of user fees with targeting: Developing equitable health financing policy. J Int Devel 1995;7:369–401.

User fees, price system, lowresource settings, healthcare systems
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How to Cite
Pagiwa, V. (2021). Economic contestation over user fees in low-resourced healthcare systems: A literature review. Healthcare in Low-Resource Settings, 9(1).