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[afro-nets] The impact of user fees on access to health services in low- and middle-income countries

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

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: 

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

Available online at:

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 


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 

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 utilization 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 

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.

Ruggiero, Mrs. Ana Lucia (WDC)
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