SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
March, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
User fees are charges paid by users of healthcare services at the point of use. They are supposed to help reduce ‘frivolous’ use of health services, as well as raise revenue to pay for services. If used appropriately, user fees might also motivate health professionals and improve the quality of care. However, they might also reduce appropriate use of services.
-introducing or increasing user fees reduces utilisation,
-the combination of user fees and quality improvement increases utilisation, and
-removing or reducing user fees increases utilisation.
Lagarde M, Palmer N. The impact of user fees on access to health services in low and middle income countries. Cochrane Database Syst Rev 2011 (4): CD009094.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
As a financial barrier, user fees should deter people from seeking needless healthcare, and when patients pay them they constitute a source of revenue for the facility or the system. However, user fees might also deter people from seeking necessary healthcare.
Economic theory predicts that an increase in the price of a specific good will lead to a decrease in its consumption. Advocates of user fees have argued that the collected revenue would, however, improve the quality of services delivered, and hence compensate for the negative effects of user fees. However, increased poverty and poor social indicators in many countries led to growing concerns about the detrimental role played by user fees. In particular, the failure of exemption schemes in cost recovery systems led to the realisation that a growing part of the population was excluded from the health system while others were facing catastrophic health expenditures.
| Review objectives: To assess the effects of introducing, removing, or changing user fees on the access of different populations to care in low and middle income countries | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised trials, interrupted time series studies, and controlled before after studies of introducing, removing, or changing user fees |
Randomised trials (2), interrupted time series studies (9), and controlled before and after studies (6) evaluating the introduction of user fees (8 studies), the removal of fees (5), and increasing or decreasing fees (5). |
| Participants | People living in low and middle income countries |
Users or potential users of outpatient facilities (8 studies), hospitals (3), both (5), or preventive drugs (school children) (1) |
| Settings | Any setting where health services are provided |
Kenya (4 studies), Ecuador (2), Uganda (2), and 1 each from Burkina Faso, Cameroon, Colombia, Gabon, Lesotho, Niger, Papa New Guinea, South Africa, and Sudan |
| Outcomes | Use of health services, healthcare costs, health outcomes, and equity |
Utilisation of services (14 studies), number of new patients (2), health-seeking behaviour (2) |
| Date of most recent search: February 2011 | ||
| Limitations: This is a well conducted systematic review with only minor limitations. | ||
Lagarde M, Palmer N. The impact of user fees on access to health services in low and middle income countries. Cochrane Database Syst Rev 2011 (4): CD009094.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
Included studies suggest that introducing user fees decreases utilisation, but it is unclear whether this reduction persisted over time. Two studies suggest that the combination of user fees and improvements in quality can increase utilisation.
Studies suggest that removing user fees increases the utilisation of curative healthcare services, usually in the form of a sharp increase following fee removal. Removing user fees might also have a positive impact on the uptake of preventive services after a year. Other included studies suggest that reducing user fees has a positive impact on the uptake of health services, and that the size of this impact varies with the size of the fee reduction.
The included studies suggest that an increase (or a decrease) in the level of fees leads to a more than proportional decrease (or an increase) in the utilisation of health services, indicating that the demand for healthcare is elastic.
However, the impacts of changing user fees is uncertain because of very low certainty of the evidence.
Introduction of user fees |
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| People: Anyone using any type of health service in low and middle income countries Settings: Burkina Faso, Kenya, Lesotho, Papua New Guinea Intervention: Introduction of user fees Comparison: No user fees |
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| Outcomes | Relative change in utilsation |
Certainty of the evidence* |
Comments | |
| Utilisation of preventive services |
-15.4% immediately -17% after 12 months |
Very low |
Antenatal care visits dropped in one study where fees were introduced. One additional study found a decrease in utilisation of deworming drugs following an introduction of fees. | |
| Utilisation of curative services |
-28% to -51% immediately -9% to +8% after 12 months |
Very low |
Four of six studies showed a decrease in the number of outpatient visits in different types of facilities, although some drops in attendance might have been by chance. | |
| Equity | Not reported | Very low | One study where quality improvements were introduced at the same time as user fees found an increase in utilisation for poor groups. | |
| *GRADE: GRADE Working Group grades of evidence (see above and last page) |
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Increasing user fees |
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| People: Anyone using any type of health service in low and middle income countries. Settings: Ecuador, Gabon. Intervention: Increasing user fees. Comparison: Previous user fees. |
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| Outcomes | Net elasticity of the demand for services* |
Certainty of the evidence+ |
Comments | |
| Preventive services |
-0.1 to -0.2 |
Very low |
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| Curative services |
-0.2 to -2.8 |
Very low |
Each of two studies had 2 arms - in three out of four arms, the results showed elasticities smaller than -1. | |
| Equity | Not reported | |||
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*Calculated as relative % change in utilisation of services/% change in fees. This represents the degree to which use of health services changes when user fees are changed. †GRADE: GRADE Working Group grades of evidence (see above and last page) |
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Removing user fees |
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| People: Anyone using any type of health service in low and middle income countries. Settings: Kenya, South Africa, Uganda. Intervention: Removal of user fees. Comparison: Previous user fees. |
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| Outcomes | Relative change in utilsation |
Certainty of the evidence* |
Comments | |
| Utilisation of preventive services |
+1.3% to +249% immediately +5% to +92% after 12 months |
Very low |
Most of the immediate changes might have been by chance, but several of the changes after 12 months were unlikely to have been by chance. | |
| Utilisation of curative services |
-28% to -51% immediately -9% to +8% after 12 months |
Very low |
There was an increase in the uptake of outpatient visits across studies. Inpatient visits did not increase in the one study that measured this. | |
| Equity | Not reported | |||
| *GRADE: GRADE Working Group grades of evidence (see above and last page) | ||||
Decreasing user fees |
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| People: Anyone using any type of health service in low and middle income countries. Settings: Colombia, Sudan. Intervention: Decreasing user fees. Comparison: Previous user fees. |
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| Outcomes | 'Net' elasticity of the demand of services* |
Certainty of the evidence* |
|
| Preventive and curative services |
0 to -6.23 |
Very low |
|
| Equity |
Not reported |
- | |
|
*Calculated as relative % change in utilisation of services/% change in fees. This represents the degree to which use of health services changes when user fees are changed. †GRADE: GRADE Working Group grades of evidence (see above and last page) |
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| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
| Most of the included studies were from low income countries. |
The impacts of changes in user fees on utilisation are uncertain and may depend on whether they are for preventive or curative services, whether increases are combined with quality improvement efforts, and the size of the change in fees. |
| EQUITY | |
| Differential impacts on poorer populations were only reported in one study where quality improvements were introduced at the same time as user fees. |
Poorer people may be more sensitive to changes in user fees. |
| ECONOMIC CONSIDERATIONS | |
| The review did not report economic consequences of changes to user fees. |
Revenue generated by increasing user fees may be limited and there may be management and capacity constraints on facilities’ abilities to retain user fees and use them effectively.
|
| MONITORING & EVALUATION | |
| The certainty of the evidence is very low. |
Changes to user fees should be carefully planned and monitored. The impacts of changes to user fees should be rigorously evaluated. |
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods |
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Ridde V, Morestin F. A scoping review of the literature on the abolition of user fees in health care services in Africa. Health Policy Plan 2011; 26:1-11.
James CD, Hanson K, McPake B, et al. To retain or remove user fees? Reflections on the current debate in low and middle income countries. Appl Health Econ Health Policy 2006; 5:137-53.
Gilson L, McIntyre D. Removing user fees for primary care in Africa: the need for careful action. BMJ 2005; 331:762-5.
Rezayatmand R, Pavlova M, Groot W. The impact of out of pocket payments on prevention and health related lifestyle: a systematic literature review. Eur J Public Health 2013; 23:74-9.
Andy Oxman, Norwegian Institute of Public Health, Oslo, Norway
None known. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Kent Ranson and Mylene Lagarde.
Lagarde M, Palmer N. The impact of user fees on access to health services in low and middle income countries. Cochrane Database Syst Rev 2011 (4): CD009094.
Oxman AD. What are the impacts of changes in user fees on access to health services? A SUPPORT Summary of a systematic review. March 2017. www.supportsummaries.org
evidence informed health policy, evidence based, systematic review, health systems research, health care, low and middle income countries, developing countries, primary health care, user fees, out of pocket payments, utilisation, access
