August, 2008 - SUPPORT Summary of a systematic review | print this article |

Do user fees have an impact on access to health services?

User fees are charges at the point of use for any aspect of health services. Due to scant financial resources, many low and middle-income countries decided to introduce them to raise additional revenue. It was argued that they would help reduce ‘frivolous’ consumption of health services, and increase the quality of services and equity of consumption through the resources they would yield.

Key messages

  • The review concludes that all other factors remaining the same, increasing the price of health services tends to decrease demand.
  • A number of questions pertaining to impact on equity or health status, and the effects of simultaneously introducing user fees and quality improvement strategies remain unanswered due to the absence or quality of existing evidence.


User fees are charges levied at the point of use for any aspect of health services: registration fee, consultation fee, fees for drugs and medical supplies or any health service rendered. Fees can be paid for each visit or can encompass an entire episode of illness. According to its supporters, user fees are supposed to fulfil three objectives: 1) to improve efficiency of use and diminish “frivolous” consumption, 2) to raise revenue to complement traditional funding sources (the public budget) and therefore sometimes allow for improved personnel motivation and service quality, and 3) to improve the equity of distribution of health services in a given country through the reallocation of resources collected through user fees. On the other hand, there are concerns over the implications of user fees for equity in access since utilization can decrease, especially in disadvantaged populations, with an increase in user fees. In addition, user fees are generally regressive - the payment is the same per service regardless of income.

About the systematic review underlying this summary

Summary of findings

The review included two cluster-randomised trials, six controlled before-after studies and nine interrupted time-series analyses. Most studies had some methodological limitations. All the studies included were in low and middle-income countries. Most included studies focused on outpatient fees in general. None of the studies reported effects on patient drug expenditures or health outcomes. Based on this weak evidence, it seems that user fees have a detrimental effect on health service utilization. However, when associated with other factors, such as significant quality improvement efforts, user fees could increase service use.

1) Introduction or increase in user fees

The review included eight studies from five countries. In general these studies reported changes in outpatient visits. The evidence on the impact of introducing or increasing user fees is equivocal mainly due to the weaknesses of the studies.

  • There is equivocal evidence of low quality of the effects of user fees on health care utilization.




2) Removal or decrease in user fees

Five studies reported the impact on health utilization of removing user charges: two of them evaluated the implemented of a national policy in Uganda, one a nationally implemented policy change in South Africa, and the last two were done in Kenya. All of the studies reported utilisation data obtained from facility registers, and all studies suffered from concurrent major external changes that may have affected the utilization of health services.

The review concludes that in general removing user fees in low-income settings seems overall to have a positive immediate impact on utilization.

  • There is low quality evidence that suggests that removing user fees in low-income settings seems to have a positive impact on health care utilization.

Relevance of the review for low-income countries

Additional information

Related literature

This systematic review is currently in press: Lagarde M, Palmer N. The impact of user fees on access to health services in low and middle income countries. Cochrane Database of Systematic Reviews.


The protocol for the systematic review above: The impact of health financing strategies on access to health services in low and middle income countries (Protocol). Cochrane Database of Systematic Reviews 2006, Issue 3..


This chapter summarizes the financing mechanisms of health systems: The World Health Report 2000 - Health systems: improving performance. Chapter 5: Who pays health systems?. Geneva: WHO, 2000.


Review of the impacts of user fees: Creese, A. L. (1991). "User charges for health care: a review of recent experience." Health Policy Plan 1991; 6:309-19.


Review evaluating the impact and monitoring of social interventions: Savedoff, W. D., R. Levine, et al.).When Will We ever learn? Improving Lives Through Impact Evaluation Washington, D.C., Evaluation Gap Working Group, Center for Global Development.


This summary was prepared by

García Marti Sebastían and Ciapponi Agustín. Institute for Clinical Effectiveness and Health Policy. Argentina


Conflict of interest

None declared. For details, see:



This summary has been peer reviewed by: Lucy Gilson, South Africa; David Evans, Switzerland; Tracey Perez Koehlmoos, Bangladesh; Blanca Peñaloza and Francisca Florenzano, Chile; Pierre Ongolo Zogo, Cameroon.


This summary should be cited as

García Martí S, Ciapponi A. Do user fees have an impact on the access to health services? A SUPPORT Summary of a systematic review. August 2008.