abstract: 'Background: Since the advent of health user fees in low- and

  middle-income countries in the 1980s, the discourse of global health

  actors (GHAs) has changed to the disadvantage of this type of healthcare

  financing mechanism. The aim of the study was to identify and analyze

  the stance of GHAs in the debate on user fees.

  Methods: We conducted documentary research using public documents

  published by and officially attributed to GHAs from 2005 to 2011. We

  categorized GHAs into four groups: intergovernmental organizations,

  international non-governmental organizations, government agencies, and

  working groups and networks. We then classified the GHAs according to

  their stance relative to the abolition of user fees, and conducted a

  thematic analysis of their discourse to understand the arguments used by

  each GHA to justify its stance.

  Results: We identified 56 GHAs, for which we analyzed 140 documents.

  Among them, 55\% were in favor of the abolition of user fees or in favor

  of free care at the point of delivery. None of the GHAs stated that they

  were in favor of user fees; however, 30\% did not take a stand. Only the

  World Bank declares that it is both in favor of user fees and in favor

  of free care at point of service. GHAs generally circumscribe their

  stance to specific populations (pregnant women, children under 5 years,

  etc.) or to specific health services (primary, basic, essential). Three

  types of arguments are used by GHAs to justify their stance: economic,

  moral and ethical, and pragmatic.

  Conclusions: The principle of ``user pays{''''} seems to have fizzled.

  Production and dissemination of evidence, as well as certain advocacy

  networks, may have contributed to this change in discourse. However,

  GHAs should go a step further and translate their words into action, so

  that free healthcare at the point of delivery becomes a reality in low-

  and middle-income countries. They should provide technical and financial

  support to those countries that have chosen to implement user fee

  exemption policies, sometimes influenced by a GHA.'
affiliation: 'Robert, E (Corresponding Author), Univ Montreal, Fac Med, CRCHUM, Pavillon
  Masson,3850,Rue St Urbain, Montreal, PQ H2W 1T7C, Canada.

  Robert, Emilie; Ridde, Valery, Univ Montreal, Fac Med, CRCHUM, Montreal, PQ H2W
  1T7C, Canada.

  Ridde, Valery, Univ Montreal, Dept Med Social \& Prevent, Montreal, PQ H2W 1T7C,
  Canada.'
article-number: '29'
author: Robert, Emilie and Ridde, Valery
author-email: emilie.robert.3@umontreal.ca
author_list:
- family: Robert
  given: Emilie
- family: Ridde
  given: Valery
da: '2023-09-28'
doi: 10.1186/1744-8603-9-29
eissn: 1744-8603
files: []
journal: GLOBALIZATION AND HEALTH
keywords: 'User fees; LMICs; International health policy; Global health actors;

  Policy change'
keywords-plus: 'LOW-INCOME COUNTRIES; STAKEHOLDER ANALYSIS; PUBLIC-HEALTH; POLICY;
  CARE;

  COVERAGE; LESSONS; REFORMS; AFRICA; NEED'
language: English
month: JUL 26
number-of-cited-references: '111'
orcid-numbers: 'Ridde, Valery/0000-0001-9299-8266

  Robert, Emilie/0000-0002-2260-1873'
papis_id: 6221ddb94e462dd475bda1a9c1633311
ref: Robert2013globalhealth
researcherid-numbers: 'ridde, valery/AAV-1016-2020

  Ridde, Valery/AAD-2736-2019

  '
times-cited: '32'
title: 'Global health actors no longer in favor of user fees: a documentary study'
type: Article
unique-id: WOS:000323004200001
usage-count-last-180-days: '0'
usage-count-since-2013: '7'
volume: '9'
web-of-science-categories: Public, Environmental \& Occupational Health
year: '2013'