The impact of user fees on access to health services in low- and middle-income countries.

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Lagarde, M ; Palmer, N (2011)

: Following an international push for financing reforms, many low- and middle-income countries introduced user fees to raise additional revenue for health systems. User fees are charges levied at the point of use and are supposed to help reduce 'frivolous' consumption of health services, increase quality of services available and, as a result, increase utilisation of services.<br/> : To assess the effectiveness of introducing, removing or changing user fees to improve access to care in low-and middle-income countries<br/> : We searched 25 international databases, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group's Trials Register, CENTRAL, MEDLINE and EMBASE. We also searched the websites and online resources of international agencies, organisations and universities to find relevant grey literature. We conducted the original searches between November 2005 and April 2006 and the updated search in CENTRAL (DVD-ROM 2011, Issue 1); MEDLINE In-Process & Other Non-Indexed Citations, Ovid (January 25, 2011); MEDLINE, Ovid (1948 to January Week 2 2011); EMBASE, Ovid (1980 to 2011 Week 03) and EconLit, CSA Illumina (1969 - present) on the 26th of January 2011.<br/> : We included randomised controlled trials, interrupted time-series studies and controlled before-and-after studies that reported an objective measure of at least one of the following outcomes: healthcare utilisation, health expenditures, or health outcomes.<br/> : We re-analysed studies with longitudinal data. We computed price elasticities of demand for health services in controlled before-and-after studies as a standardised measure. Due to the diversity of contexts and outcome measures, we did not perform meta-analysis. Instead, we undertook a narrative summary of evidence.<br/> : We included 16 studies out of the 243 identified. Most of the included studies showed methodological weaknesses that hamper the strength and reliability of their findings. When fees were introduced or increased, we found the use of health services decreased significantly in most studies. Two studies found increases in health service use when quality improvements were introduced at the same time as user fees. However, these studies have a high risk of bias. We found no evidence of effects on health outcomes or health expenditure.<br/> : The review suggests that reducing or removing user fees increases the utilisation of certain healthcare services. However, emerging evidence suggests that such a change may have unintended consequences on utilisation of preventive services and service quality. The review also found that introducing or increasing fees can have a negative impact on health services utilisation, although some evidence suggests that when implemented with quality improvements these interventions could be beneficial. Most of the included studies suffered from important methodological weaknesses. More rigorous research is needed to inform debates on the desirability and effects of user fees.<br/>
  • References (25)
    25 references, page 1 of 3

    The search to identify studies for this review was initially done as a part of a much wider review on health financing mechanisms (Lagarde 2006) dealing with the effects of several financing strategies. The broad review has been split into several sub-reviews, including the present one. Therefore the search methodology includes terms that encompass a broader scope that the one defined for this review.

    We searched 25 international databases, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group's Trials Register, CENTRAL, MEDLINE and EMBASE. We also searched the websites and online resources of international agencies, organisations and universities to nd relevant grey literature.

    We originally searched the following electronic databases without language or date restrictions: • The Cochrane EPOC Group Trials Register (and the database of studies awaiting assessment), 20/01/2006 • The Cochrane Central Register of Controlled Trials (CENTRAL) The Cochrane Library, 20/01/2006 • MEDLINE, 11/11/2005 • EMBASE (Athens), 19/04/2006 • Popline, 08/12/2005 • African Healthline (bibliographic databases on African health issues), 28/04/2006 • IBSS (International Bibliography in Social Sciences, Athens interface), 19/04/2006 • The Database of Abstracts of Reviews of Effectiveness, 20/ 01/2006 • BLDS, 03/11/2005 • ID21, 24/11/2005 • ELDIS, 25/11/2005 • The Antwerp Institute of Tropical Medicine database, 26/ 01/2006 • Jstor, 26/01/2005 • Inter-Science (Wiley), 16/12/2005 • ScienceDirect, 16/12/2005 • IDEAS(Repec), 20/01/2005 • LILACS, 19/04/2006 • CAB-Direct (Global Health), 17/04/2006 • Healthcare Management Information Consortium (HMIC), 17/04/2006 • World Health Organization Library Information System (WHOLIS), 18/04/2006 • MEDCARIB, 19/04/2006 • ADOLEC, 19/04/2006 • FRANCIS, 16/12/2005 • BDSP, 16/12/2005 • USAID database, 04/11/2005.

    We developed the MEDLINE search strategy mainly using reviews cited in the background section of the protocol (Lagarde 2006) and their references. The strategy includes terms for the following types We performed an updated search of the following databases on January 26, 2011: • The Cochrane Central Register of Controlled Trials (CENTRAL DVD-ROM) 2011, Issue 1, part of the The Cochrane • MEDLINE In-Process & Other Non-Indexed Citations, Ovid (January 25, 2011) • MEDLINE, Ovid (1948 to January Week 2 2011) • EMBASE, Ovid (1980 to 2011 Week 03) • EconLit, CSA Illumina (1969 - present) R E S U L T S O F Ridde 2003 {published data only} Ridde V. Fees-for-services, cost recovery, and equity in a district of Burkina Faso operating the Bamako Initiative. Bulletin of the World Health Organization 2003; Vol. 81, issue 7:532-8.

    Wilkinson 2001 {published data only} Wilkinson D, Gouws E, Sach M, Karim SS. Effect of removing user fees on attendance for curative and preventive primary health care services in rural South Africa. Bulletin of the World Health Organization 2001; Vol. 79, issue 7: 665-71.

    References to studies excluded from this review Akashi 2004 {published data only} Akashi H, Yamada T, Huot E, Kanal K, Sugimoto T. User fees at a public hospital in Cambodia: effects on hospital performance and provider attitudes. Social Science and Medicine 2004;58(3):553-64.

    Cohen 2010 {published data only} Cohen J, Dupas P. Free distribution or cost-sharing? Evidence from a randomized malaria prevention experiment. Quarterly Journal of Economics 2010;125(1):1-45.

    Deininger 2005 {published data only} Deininger K, Mpuga P. Economic and welfare Impact of the abolition of health user fees: evidence from Uganda. Journal of African Economies 2005;14(1):55-91.

    Ellis 1994 {published data only} Ellis RP, Chawla M. Demand side impacts: Experiment in health care cost recovery in Niger. Bethesda, MD: Abt Associates, 1994.

    Jacobs 2004 {published data only} Jacobs B Price N. The impact of the introduction of user fees at a district hospital in Cambodia. Health Policy and Planning 2004;19(5):310-21.

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