In Madagascar, Use Of Health Care Services Increased When Fees Were Removed: Lessons For Universal Health Coverage

Health Aff (Millwood). 2017 Aug 1;36(8):1443-1451. doi: 10.1377/hlthaff.2016.1419.


Despite overwhelming burdens of disease, health care access in most developing countries is extremely low. As governments work toward achieving universal health coverage, evidence on appropriate interventions to expand access in rural populations is critical for informing policies. Using a combination of population and health system data, we evaluated the impact of two pilot fee exemption interventions in a rural area of Madagascar. We found that fewer than one-third of people in need of health care accessed treatment when point-of-service fees were in place. However, when fee exemptions were introduced for targeted medicines and services, the use of health care increased by 65 percent for all patients, 52 percent for children under age five, and over 25 percent for maternity consultations. These effects were sustained at an average direct cost of US$0.60 per patient. The pilot interventions can become a key element of universal health care in Madagascar with the support of external donors.

Keywords: health care access; health equity; health system strengthening; universal health coverage; user fee exemptions.

MeSH terms

  • Adult
  • Child, Preschool
  • Developing Countries
  • Fees and Charges*
  • Female
  • Health Services Accessibility / economics*
  • Health Services* / economics
  • Health Services* / statistics & numerical data
  • Humans
  • Infant
  • Infant, Newborn
  • Insurance, Health / economics*
  • Madagascar
  • Male
  • Quality of Health Care
  • Rural Population
  • Universal Health Insurance / economics*