countries. A 1995 survey of 37 African countries found that 34 governments impose fees of some kind for government-provided health services (cited in Shaw and Griffin, 1995). This section briefly reviews the main objectives of user fees, the experience from implementation, and implications for women's reproductive health services.

User fees tend to be used in the public sector for three reasons: to mobilize resources, to target public spending to the poor, and to improve efficiency by giving consumers appropriate price signals. For governments in developing countries, revenue generation is usually the main motivation for introducing user fees. Experience indicates that user fees usually contribute a modest amount to government costs—an estimated 4 to 20 percent in sub-Saharan Africa (Shaw and Griffin, 1995)—although in some cases, this is offset by fairly high collection costs. If user fees are largely retained and reinvested at the local facility level, they can improve the quality of services (Foreit and Levine, 1993). Some studies have shown that user fees can actually increase the use of health services by the poor if they are successfully used to improve the quality of services (Litvack and Bodart, 1993). A by-product of user fees is that they may make publicly run facilities more accountable to clients: clients tend to demand more responsive services when they are paying directly for them, especially if local communities are involved in the design and application of user fees.

Some social services in developing countries attempt to target subsidies, either by charging fees on a sliding scale (so that the poorest clients pay less than others), by charging higher fees in locations used mainly by those who can afford to pay, or by charging fees for service at certain hours when waiting times are low (Grosh, 1994). Sliding-scale arrangements can be difficult to administer and are subject to abuse, but if the poorest clients can be readily identified, clinics can charge fees from those better able to afford them without discouraging use of services by the poor. Targeting subsidies by charging fees at some clinics and not others is feasible insofar as the poor live apart from the less poor or use different facilities.

User fees can be used to improve efficiency in a variety of ways. User fees can be used to support a referral system by charging patients who go directly to tertiary facilities for care that should be provided at lower level facilities. User fees at tertiary facilities provide an incentive for patients to seek care at lower levels. User fees can be applied to influence the demand for services: services with high positive externalities (such as STD prevention) can be provided free or almost free of charge so that demand is not curtailed, while services with largely private benefits can carry higher user fees.

Some have argued that user fees should not be imposed for prenatal and delivery care in order to help ensure that babies enter the maternal-child



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