- Open Access
BMC Health Services Researchvolume 15, Article number: I1 (2015)
Universal Health Coverage (UHC) is increasingly gaining centre stage in the post 2015 international development agenda . After years of debate [2–4], a consensus has gradually emerged that UHC is "an affordable dream"  that can have a significant impact on people's individual and collective wellbeing. Comprehensive monitoring frameworks to measure progress towards UHC are being developed . Eventually, UHC is seen as a vehicle to bring about health equity .
The concern for equity in health is of course all but new . However, equity as a moral imperative has not always been a prime concern in health financing . Back in the 1980s, efficiency was the dominant driver of health financing reforms under structural adjustment. Corrective measures such as fee exemptions for indigents followed, but rarely proved to be effective [10–12]. To this added a growing body of evidence on the negative impact of user fees on health equity [13–16]. It is thus no wonder that the UHC debate at the beginning of the 21st century renewed and boosted interest in equity [17–20].
Designing and implementing equity-oriented strategies remains, however, a key challenge in low- and middle-income countries . Policymakers and implementers increasingly demand practical insights and knowledge , on which the otherwise copious UHC literature is particularly silent. Jim Yong Kim, President of the World Bank, recently made a case for "science of delivery", i.e. a science of implementation and execution . We are witnessing a shift from the 'what' and 'why' questions to the 'how' question: how to steer complex policy processes in a way that enhances equity in health . Over recent years, many policymakers in sub-Saharan Africa have opted for exemption policies to lower financial barriers to health care. In West Africa, this has led to a range of user-fee exemptions for vulnerable populations (e.g. children under-5, pregnant women), life-saving interventions (e.g. C-sections) or a combination of both (e.g. malaria treatment for under-5s).
To date, research investigating fee exemption policies by and large remains confined to their (quantitative) impact on utilisation rates, the most frequently used proxy for access to health care . This type of evidence is obviously relevant, but hardly provides insight in how and why exemption policies work (or not). Limited evidence on the mechanisms of success and failure shows mixed results [26–31], with two conclusions systematically surfacing: the impact of fee exemptions is highly context-dependent; its understanding requiring in-depth exploration of both intended and unintended effects.
This special issue on fee exemption policies in West Africa couldn't be more timely. In the papers presented in this issue, the authors present results from research conducted by a range of teams led by Valéry Ridde and Jean-Pierre Olivier de Sardan in Mali, Niger and Burkina Faso over the past 5 to 10 years. The question of implementation is central in all the contributions.
Exploring policy implementation requires a certain level of flexibility, adapting and combining research methods in a way that enables the capture of complex social processes. This is precisely what the contributors to this special issue did. They present interesting examples of research endeavours, conducted simultaneously or successively, borrowing from various disciplines: history, sociology, political science, anthropology, and of course public health. The added value of such a blended approach - allowing for in-depth analysis of social, political, economic and cultural dimensions of public policies - cannot be underestimated.
We are confident that this issue will feed into the current debates on how to develop health equity intervention research . More specifically, it will help to improve evaluation methodologies that capture contextual and other critical influences to understand what works to make significant progress towards UHC and how and why it does. Ultimately, such comprehensive knowledge can pave the way for transformative policies [33, 34], a necessary condition for health equity.
Brolan CE, Hill PS: Countdown for health to the post-2015 UN Sustainable Development Goals. Med J Aust. 2015, 202 (6): 289-290.
O'Connell T, Rasanathan K, Chopra M: What does universal health coverage mean?. Lancet. 2014, 383 (9913): 277-279.
Frenz P, Vega J: Universal health coverage with equity: what we know, don't know and need to know. [Online] Available from: http://healthsystemsresearch.org/hsr2010/images/stories/9coverage_with_equity.pdf
Kutzin J: Anything goes on the path to universal health coverage?. Bull World Health Organ. 2012, 90 (11): 867-868.
Sen A: Universal healthcare: the affordable dream. 2015, [Online] Available from: http://www.theguardian.com/society/2015/jan/06/-sp-universal-healthcare-the-affordable-dream-amartya-sen
World Health Organisation, The World Bank: Tracking Universal Health Coverage: First Global Monitoring Report. [Online] Available from: http://www.who.int/healthinfo/universal_health_coverage/report/2015/en/
Tangcharoensathien V, Mills A, Palu T: Accelerating health equity: the key role of universal health coverage in the Sustainable Development Goals. BMC Medicine. 2015, 13 (1): 101-
Sen A: Why health equity?. Health Econ. 2002, 11 (8): 659-666.
Etienne CF: Achieving universal health coverage is a moral imperative. Lancet. 2014, 385 (9975): 1271-1273.
Soors W, Dkhimi F, Criel B: Lack of access to health care for African indigents: a social exclusion perspective. Int J Equity Health. 2013, 12: 91-
Bitran R, Giedion U: Waivers and exemptions for health services in developing countries. Washington
Stierle F, Kaddar M, Tchikaya A, Schmidt-Ehry B: Indigence and access to health care in sub-Saharan Africa. Int J Health Plann Manage. 1999, 14 (2): 81-105.
Lagarde M: The impact of user fees on health service utilization in low- and middle-income countries: how strong is the evidence?. Bull World Health Organ. 2008, 86 (11): 839-848.
Lagarde M, Palmer N: The impact of user fees on access to health services in low- and middle-income countries. Cochrane Database Syst Rev. 2011, 4: CD009094-
Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJL: Household catastrophic health expenditure: a multicountry analysis. Lancet. 2003, 362 (9378): 111-117.
Dzakpasu S, Powell-Jackson T, Campbell OM: Impact of user fees on maternal health service utilization and related health outcomes: a systematic review. Health Policy Plan. 2014, 29 (2): 137-150.
Evans DB, Hsu J, Boerma T: Universal health coverage and universal access. Bull World Health Organ. 2013, 546-546A. 91:
Evans DB, Marten R, Etienne C: Universal health coverage is a development issue. Lancet. 2012, 380 (9485): 864-865.
Garrett L, Chowdhury a MR, Pablos-Méndez A: All for universal health coverage. Lancet. 2009, 374 (9697): 1294-1299.
World Health Organisation: World Health Report - Health Systems Financing: The path to Universal Coverage. [Online] Available from: http://www.who.int/whr/2010/en/
Östlin P, Schrecker T, Sadana R, Bonnefoy J, Gilson L, Hertzman C, et al: Priorities for research on equity and health: towards an equity-focused health research agenda. PLoS Med. 2011, 8: e1001115-
Nicholson D, Yates R, Warburton W, Fontana G: Delivering Universal Health Coverage: A Guide for Policymakers. [Online] Available from: http://wish-qatar.org/summit/2015-summit/reports-en/universal-health-coverage-en
Nicholson D: Universal health coverage: reaching a consensus. Lancet. 2015, 385 (9971): 838-
Horton R, Das P: Universal health coverage: not why, what, or when--but how?. Lancet. 2014, 385 (9974): 1156-1157.
Samson M, van Katwyk S, Fröling M, Ndoro R: Methods of Measuring the Impacts of Social Policy in Political, Economic and Social Dimensions. [Online] Available from: http://www.unrisd.org/80256B3C005BCCF9/search/B4A900D9DDEF4EA6C1257DEF004F1780?OpenDocument
Kanchebe Derbile E, van der Geest S: Repackaging exemptions under National Health Insurance in Ghana: how can access to care for the poor be improved?. Health Policy Plan. 2013, 28 (6): 586-595.
Witter S, Arhinful DK, Kusi A, Zakariah-Akoto S: The experience of Ghana in implementing a user fee exemption policy to provide free delivery care. Reprod Health Matters. 2007, 15 (30): 61-71.
Witter S, Adjei S, Armar-Klemesu M, Graham W: Providing free maternal health care: ten lessons from an evaluation of the national delivery exemption policy in Ghana. Glob Health Action. 2009, 1-5. 2
El-Khoury M, Hatt L, Gandaho T: User fee exemptions and equity in access to caesarean sections: an analysis of patient survey data in Mali. Int J Equity Health. 2012, 11: 49-
Agha S: Changes in the proportion of facility-based deliveries and related maternal health services among the poor in rural Jhang, Pakistan: results from a demand-side financing intervention. Int J Equity Health. 2011, 10: 57-
Ridde V, Queuille L, Kafando Y, Robert E: Transversal analysis of public policies on user fees exemptions in six West African countries. BMC Health Serv Res. 2012, 12: 409-
Commission on Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health. [Online] Available from: http://apps.who.int/iris/bitstream/10665/43943/1/9789241563703_eng.pdf
Devereux S, Sabates-Wheeler R: Transformative social protection. [Online] Available from: http://www2.unicef.org/socialpolicy/files/Transformative_Social_Protection.pdf
Michielsen J, Meulemans H, Soors W, Ndiaye P, Devadasan N, De Herdt T, et al: Social protection in health: the need for a transformative dimension. Trop Med Int Health. 2010, 15 (6): 654-658.
This article has been published as part of BMC Health Services Research Volume 15 Supplement 3, 2015: User Fee Exemption Policies. The full contents of the supplement are available online at http://www.biomedcentral.com/bmchealthservres/supplements/15/S3.