March, 2017 - SUPPORT Summary of a systematic review | print this article |

What are the impacts of changes in user fees on access to health services?

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.

 

Key messages

 

  • There is some evidence that suggests

-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.

 

  • However, these effects are uncertain because of very low certainty of the evidence.
  • The impacts of changes in user fees on utilisation 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.
  • The impact of changes in user fees on equity are uncertain. However, poorer people may be more sensitive to changes in user fees.
  • Changes to user fees should be carefully planned and monitored, and the impacts of changes to user fees should be rigorously evaluated.

 

Background

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.

 



About the systematic review underlying this summary

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.

Summary of findings

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.

 

  • There is some evidence that introducing or increasing user fees reduces utilisation, that the combination of user fees and quality improvement increases utilisation, and that removing or reducing user fees increases utilisation, but these effects are uncertain. The certainty of this evidence is very low.

 

 

Introduction of user fees

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
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)

 

 

 

 

Increasing user fees

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.
Outcomes Net elasticity of the demand for services*
Certainty of the evidence+
Comments
Preventive services
-0.1 to -0.2
Very low
 
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    

*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)

 

 

 

 

Removing user fees

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.
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

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.
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)

 


 

Relevance of the review for low-income countries

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.

 

  • Poorly planned or resourced removal of user fees (e.g. not increasing drug supplies or managing the motivation of health workers faced with an increased workload) may have adverse effects.

 


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.


*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

 

Additional information

Related literature

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.

 

This summary was prepared by

Andy Oxman, Norwegian Institute of Public Health, Oslo, Norway

 

Conflict of interest

None known. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Kent Ranson and Mylene Lagarde.

 

This review should be cited as

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.

 

The summary should be cited as

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

 

Keywords

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

 

 

 

 

 

 

 

 



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