User fees for health care in developing countries: a case study of Bangladesh

In designing country health care programs to achieve the goals of the Alma Alta declaration of 'Health for All', developing countries have been confronted with the problem of increased health care needs and decreased available resources. Health economists have proferred several possible solutions to this fiscal shortfall, including cost-recovery measures through the imposition of user fees for curative services at government health facilities. Health care providers have been noticeably absent from discussions of the many possible implications of these fees; consequently, resultant programs and policies may be economically sound but may fail to place a sufficient emphasis on features designed to maintain and improve the health of the population. In the present paper we examine the possible impact of user fees on the health of individuals residing in Bangladesh, one potential candidate country for user fees. We note evidence that the existing government health care system appears already to be providing care to two of the most medically vulnerable groups in Bangladesh, the poor and women, and provide evidence that such fees may seriously interfere with maintaining this patient profile. We discuss the significant public health role that curative care provides for the individuals, their families and the wider community. We suggest that additional questions should be asked by health care providers, anthropologists and economists prior to institution of user fees in the government system and that such measures should first be introduced in an experimental format with a rigorous and comprehensive impact evaluation.