<br>From: <b class="gmail_sendername">Ruggiero, Mrs. Ana Lucia (WDC)</b> <span dir="ltr"><<a href="mailto:ruglucia@paho.org">ruglucia@paho.org</a>></span><br><div class="gmail_quote">crossposted from: <a href="mailto:EQUIDAD@listserv.paho.org">EQUIDAD@listserv.paho.org</a><br>
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<p class="MsoNormal" style="margin-left:.5in"><span><b><font size="2" color="maroon" face="Arial"><span style="font-size:11.0pt;font-family:Arial;color:maroon">The impact of user fees on access to health services in low- and
middle-income countries</span></font></b></span></p>

<p class="MsoNormal" style="margin-left:.5in"><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black"><br>
</span></font><span><font size="1" color="black" face="Arial"><span style="font-size:9.0pt;font-family:Arial;color:black">Mylene Lagarde¹,
Natasha Palmer¹</span></font></span><font size="1" color="black" face="Arial"><span style="font-size:9.0pt;font-family:Arial;color:black"><br>
<span>¹</span><span>Department
of Global Health and Development, London
School of Hygiene & Tropical
Medicine, London, UK<br>
</span><span><b><i><span style="font-weight:bold;font-style:italic">Cochrane Database of Systematic Reviews</span></i></b></span><span><b><span style="font-weight:bold"> 2011, Issue 4</span></b></span><span>. Art. No.: CD009094. DOI: 10.1002/14651858.CD009094.</span></span></font></p>


<p class="MsoNormal" style="margin-left:.5in"><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black"><br>
<span>The Cochrane Collaboration. Published by John
Wiley & Sons, Ltd.</span> April 2011<br>
<br>
</span></font></p>

<p class="MsoNormal" style="margin-left:.5in"><span><b><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black"><br>
</span></font></b></span><span><b><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black;font-weight:normal">Available online at:</span></font></b></span><b><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black;font-weight:bold"> </span></font></b><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black"><a href="http://bit.ly/i9BXLA" target="_blank"><font color="black"><span style="color:black">http://bit.ly/i9BXLA</span></font></a>
<b><span style="font-weight:bold"><br>
<br>
</span></b></span></font></p>

<p class="MsoNormal" style="margin-right:0in;margin-bottom:12.0pt;margin-left:.5in"><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black">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>
<br>
</span></font></p>

<p class="MsoNormal" style="margin-left:.5in"><b><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black;font-weight:bold">Objectives</span></font></b></p>

<p class="MsoNormal" style="margin-right:0in;margin-bottom:12.0pt;margin-left:.5in"><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black">To assess the
effectiveness of introducing, removing or changing user fees to improve access
to care in low-and middle-income countries<br>
<br>
</span></font></p>

<p class="MsoNormal" style="margin-left:.5in"><b><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black;font-weight:bold">Search strategy</span></font></b></p>

<p class="MsoNormal" style="margin-right:0in;margin-bottom:12.0pt;margin-left:.5in"><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black">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>
<br>
</span></font></p>

<p class="MsoNormal" style="margin-left:.5in"><b><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black;font-weight:bold">Selection criteria</span></font></b></p>

<p class="MsoNormal" style="margin-right:0in;margin-bottom:12.0pt;margin-left:.5in"><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black">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>
<br>
</span></font></p>

<p class="MsoNormal" style="margin-left:.5in"><b><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black;font-weight:bold">Data collection and analysis</span></font></b></p>

<p class="MsoNormal" style="margin-right:0in;margin-bottom:12.0pt;margin-left:.5in"><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black">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>
<br>
</span></font></p>

<p class="MsoNormal" style="margin-left:.5in"><b><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black;font-weight:bold">Main results</span></font></b></p>

<p class="MsoNormal" style="margin-right:0in;margin-bottom:12.0pt;margin-left:.5in"><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black">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>
<br>
</span></font></p>

<p class="MsoNormal" style="margin-left:.5in"><b><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black;font-weight:bold">Authors' conclusions</span></font></b></p>

<p class="MsoNormal" style="margin-left:.5in"><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black">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. </span></font></p>

<p class="MsoNormal" style="margin-left:.5in"><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black"> </span></font></p>

<p class="MsoNormal" style="margin-left:.5in"><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black">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. </span></font></p>

<p class="MsoNormal" style="margin-left:.5in"><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black"> </span></font></p>

<p class="MsoNormal" style="margin-left:.5in"><font size="2" color="black" face="Arial"><span style="font-size:10.0pt;font-family:Arial;color:black">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><br></span></font></p></div></div></div>