Removing user fees for health services in low-income countries: a multi-country review framework for assessing the process of policy change

Several authors have stressed the fact that many policy reforms fail because of poor formulation or implementation. On the other hand, the health financing literature provides little guidance to policy makers in low-income countries on how to implement a health care financing reform in ways that enhance its chance of achieving policy objectives, even less so for a user fee removal reform.This paper presents the framework used for a multi-country review of the policy process of removing user fees in six sub-Saharan African countries. The review aimed at developing operational guidance for health managers involved in user fee removal reform. Drawing broadly on Walt and Gilson's 'health policy analysis triangle' (context - actor - process - content), we focused particularly on understanding the process of planning and implementing the reform led by central-level policy actors. Our core analytic strategy was the verification of a list of 'good practice hypotheses' that might be expected in a health financing policy reform against experience.This framework offers an approach for how to analyse health financing policy reform processes in low-income countries. It allows for an explicit and transparent review of multiple experiences against a set of clear hypotheses. This approach might be a step in the direction of research that supports better formulation and implementation of policies in resource-poor settings.