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

[Claudio Schuftan]

From: Ruggiero, Mrs. Ana Lucia (WDC) <ruglucia at paho.org>
crossposted from: EQUIDAD at listserv.paho.org


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


Mylene Lagarde1, Natasha Palmer1
1Department of Global Health and Development, London School of Hygiene &
Tropical Medicine, London, UK
*Cochrane Database of Systematic Reviews** 2011, Issue 4*. Art. No.:
CD009094. DOI: 10.1002/14651858.CD009094.


The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. April 2011

 *
**Available online at:** *http://bit.ly/i9BXLA *

*

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.

 *Objectives*

To assess the effectiveness of introducing, removing or changing user fees
to improve access to care in low-and middle-income countries

 *Search strategy*

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.

 *Selection criteria*

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.

 *Data collection and analysis*

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.

 *Main results*

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.

 *Authors' conclusions*

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.
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