User fee waivers for poor individuals were introduced in select areas of both Burundi and Afghanistan in 2005.13 In Afghanistan, community leaders were responsible for identifying recipient households during the waiver program. These households received waiver cards for use in facilities. However, this system was not entirely effective – 42% of cards were used by the wealthiest three quintiles while only 19% of people in the poorest quintile received a card, revealing the importance of effective identification systems in program implementation. Despite this challenge, there was an increased use of health services among individuals who had a waiver, and this trend was even more apparent among poor households.1

A few years after the pilot waiver program, Afghanistan instituted a national ban on user fees at facilities providing an established basic package of health services. There was a marked increase in curative care utilization following the ban but not preventive and promotive care, likely because these services were mostly free prior to the ban. Despite this increase in utilization of services, perceived and actual quality of care were not affected, demonstrating remarkable resilience in the face of increased utilization.2 Some strategies that contributed to the successful impact of fee removal on utilization and resilient quality of care in Afghanistan included: health education and awareness about drug use, stricter prescription practices, and supervision and monitoring to ensure adequate supplies and staffing.

In Burundi, a community project provided fee waivers for extremely impoverished households coupled with a reduced user fee for all other community members. In a community with widespread poverty, the waiver program was only able to encompass 8.6% of the population. Additionally, the reduced flat fee still posed a significant barrier to care for those who were not exempt; 87% of the population still did not have sufficient money to seek care for their last illness.3 However, the program did show some evidence of success; relative to the entire country, the province where it was implemented experienced increased access to care (58% vs. 70%, respectively). This intervention showed mixed results in the intended effect of improved access and illustrates the value of community input in design and implementation, particularly to calibrate interventions to local realities.

Following a four-decade cycle of user fee removal and re-introduction in Kenya, user fees were abolished in all public dispensaries and health centers and for all maternal services in 2013. However, implementers faced a multitude of challenges that compromised the potential benefits of the new financing arrangement.4 Increased utilization following user fee removal coupled with inadequate preparation to meet the demand resulted in high provider burden and workload. Providers reported inadequate incentives and motivation following this shift. Additionally, few county or facility-level stakeholders were consulted during the planning process resulting in a lack of buy-in and motivation. As described in “What it is”, these challenges that often arise during the abolition of user fees could be preemptively avoided through careful planning processes that ensure facility-level support to withstand accompanying increases in service utilization.


  1. Steinhardt LC, Peters DH. Targeting accuracy and impact of a community-identified waiver card scheme for primary care user fees in Afghanistan. Int J Equity Health. 2010 Nov;9:28.
  2. 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 Nov;26 Suppl 2:ii92-103.
  3. Lambert-Evans S, Ponsar F, Reid T, Bachy C, Van Herp M, Philips M. Financial access to health care in Karuzi, Burundi: a household-survey based performance evaluation. Int J Equity Health. 2009;8:36.
  4. Pyone T, Smith H, van den Broek N. Implementation of the free maternity services policy and its implications for health system governance in Kenya. BMJ Glob Heal [Internet]. 2017;2(4):e000249. Available from: