Abstract
The 2010 World Health Report reiterates the fact that direct payments are a major obstacle to universal health coverage. Removing user fees was even labelled a quick win for progressing towards the Millennium Development Goals. Health financing literature provides little guidance to policy makers in low-income countries on how to formulate and implement the reform in such a way that helps enhance its chances of achieving policy objectives. This article shares the rationale and components of the framework developed for the UNICEF multi-country review of user fee reform process in Sub-Saharan Africa. For this a list of good practice hypothesis were drawn from the literature and the professional experiences of the reviewers. All the hypotheses were rated as crucial, important and helpful based on the expertize of the authors of the framework. Drawing broadly on Walt and Gilson’s health policy analysis triangle (context-actor-process-content), the article focused particularly on understanding the process of planning and implementing the reform led by central-level policy actors. It was observed that out of the 20 hypothesis some were less supported by the literature like the sequencing of the implementation in phases, others are supported by most authors like the involvement of key implementation stakeholders in the formulation stage, need for broad communication strategies and the importance of monitoring the reform and still other hypothesis could be reformulated. They recommended that more attention be given to the contracts between the government and the providers during formulation, implementation or evaluation. The main limitation of the framework is that it does not pay attention to the interaction between actors and did not help to identify casual links between compliance with a hypothesis and the final outcome of a reform. But overall this framework offers an approach for how to analyze health financing policy reform processes in low-income countries. The framework finds a balance between putting good practice hypothesis to the test and more analytical descriptions. Further the approach of this framework, combining the use of recommendations derived from the literature, expert opinions and multiple case studies to validate the proposal good practice hypothesis, should be seen as a step towards research that supports better formulation and implementation of policies in resource-poor settings.