The impact of user fees on access to health services in low- and middle-income countries
Limited evidence suggests that introduction of user fees for health care has little public health benefit, especially with regard to improving access to services in an equitable and efficient way, or to improving health-care outcomes. Studies included in this review indicate that when fees is introduced or increased, the use of preventive and curative health-care services decreases significantly. On the other hand, removal of user fee may increase the use of preventive services, but the effect on equity, outcomes and use of inpatients services is unclear.
RHL commentary by Waiswa WP
Financing health care has always been a major challenge, especially in low- and middle-income countries. As a result, many options of raising finances have been employed, including charging of user fees for health-care services. However, the introduction of user fee policies has often been controversial. User fees are charges levied at the point of use for any aspect of health services. For example, they may be charged as registration fees, consultation fees, fees for drugs and medical supplies or charges for any health service rendered, such as outpatient or inpatient care.
User fee policies in the health sector originated almost three decades ago and were advocated for mainly by international donors. In the 1980s, diminishing funding for health care led to almost a total collapse of coverage and quality of health services in the public sector in many low- and middle-income countries. In addition, international bodies such as the World Bank and International Monitory Fund (IMF) were promoting pro-market reforms as part of their economic reforms. These reforms were also supported by UNICEF through the Bamako Initiative, which promoted ’community financing’ of primary health care (1). In response, many low- and middle-income countries introduced user fees in the hope that these would yield quality improvements and increase utilization of services, and thereby have an impact on morbidity and mortality (2).
The advocates of the user fee reforms argued that user fees would: (i) improve efficiency of use of services and diminish “frivolous” consumption; (ii) raise revenues to complement traditional funding sources (public budget) and therefore improve personnel motivation and service quality; and (iii) improve equity of distribution of health-care services in a given country through the reallocation of resources collected through user fees. The extent to which these goals were achieved in countries that implemented user fees is debatable.
Lagarde and Palmer (3) conducted the first Cochrane review of its kind to assess the impact of user fees on people’s access to health services in low- and middle-income countries. The study was motivated by the fact that recently several campaigns have advocated the removal of user fees, especially for primary care, and yet no systematic review existed which could appraises the methodological quality of empirical evidence on this topic.
2. METHODS OF THE REVIEW
In this Cochrane review, the investigators searched for all relevant studies of acceptable quality. Starting between November 2005 and April 2006, and updating in January 2011, the review authors searched 25 international databases, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group’s Trials Register, CENTRAL, MEDLINE and EMBASE. They also searched the web sites and online resources of international agencies, organizations and universities to find relevant grey literature. Studies were included if they were randomized controlled trials (RCTs), interrupted time-series studies and controlled before-and-after studies that reported an objective measure of at least one of the following outcomes: health-care utilization, health expenditures, or health-care outcomes. Data from longitudinal studies were re-analysed and the authors computed price elasticities of demand for health services in controlled before-and after studies as a standardized measure. Owing to the diversity of contexts and outcome measures, the investigators could not perform a meta-analysis, but they compiled a narrative summary of the evidence.
3. RESULTS OF THE REVIEW
The authors found only 16 studies that met their inclusion criteria out of a total of 243 identified. Even then they report that the quality of the included studies was weak and of limited reliability as most had methodological weaknesses. The key findings they reported showed that when fees were introduced or increased, the use of health-care services decreased significantly. A re-analysis of five studies found that introduction of user fees resulted in a decrease in utilization of health services, ranging from 5% to about 51% immediately after the intervention, and 8% to 55% six months after the intervention. Specifically, the findings showed that when user fees were introduced or increased people’s use of preventive and curative health-care services decreased. The findings also depict, however, that when quality improvements were made to the health services at the same time as when the user fees were introduced, people’s use of curative services increased. Only two studies found increases in health-care service use when quality improvements were introduced simultaneously with user fees. On the other hand, the review found that removal of user fees often resulted in increases in the use of health services. The findings show that immediately after the policy change, there were significant increases in the use of most curative services, ranging from 30% to 50% immediately after the policy change, and 18% to 93% 12 months later. The removal of user fees showed that there was usually no immediate impact on people’s use of preventive health-care services. However, in several cases, people’s use of these services did increase after some time. The findings show that there was some increase in the number of outpatient visits, but no increase in the number of inpatient visits. In general, user fee introduction or removal did not show any evidence of effects on health-care outcomes or health expenditure.
4.1 Applicability of the intervention
The strength of available evidence on the effect of introduction or removal of user fees on access to health services in low- and middle-income countries is weak. However, findings from this review suggest that introduction of user fees for health has little public health benefit, especially with regard to improving access to services in an equitable and efficient way, or to improving health-care outcomes. In the assessed studies, the findings showed that when fees were introduced or increased, the use of preventive and curative health-care services decreased significantly. On the other hand, the removal of user fees resulted in modest increases in the use of preventive services, but the effect on equity, outcomes and use of in-patients services was unclear.
4.2 Implementation of the intervention
There is limited evidence from this review to support wide-scale introduction of user fees. However, the available evidence suggests there could be benefits associated with removal of user fees. These findings are in line with several policy changes towards removal of user fees in a number of countries which had introduced fees earlier, as well as in agencies that had previously promoted introduction of fees (4). Recent literature shows that, since 2001, several African countries have removed user fees and the momentum towards of dismantling user fees seems to be accelerating (5, 6, 7). However, while the removal of user fees could be politically attractive and is a worthy public health goal with potential to increase access to health care for the poorest, existing evidence shows that removal of user fees needs to be well planned and managed. User fee removal should be part of a broader package of reforms which includes increased budgets to offset lost fee revenue. The removal of user fees should be widely communicated to the public and there should be careful monitoring of the process to ensure that official fees are not replaced by informal charges. Appropriate management of the alternative financing mechanisms should also be planned 8). Quick political actions leading to policy change have often lead to unintended effects, including quality deterioration due to lack of funds, excessive demands on health-care workers, depletion of drug stocks 9), and ‘crowding out’ of preventive services by curative ones 10).
4.3. Implications for research
The debate over introduction or removal of user fees has not been settled as the available evidence for or against it is week. The review found that most available studies failed a rigorous quality appraisal. In addition, given the current global budget deficits that are affecting many low- and middle-income countries, user fees as a means of raising additional income are likely to come back for consideration in national and international policies. However, these decisions need to be backed by scientific evidence. This calls for rigorous and carefully designed research to assess the impact of user fees on public health and the health services’ effectiveness, efficiency, equitable access. In addition, there is a need to understand the best modalities for implementation, improving the quality of care or even which services to target. Where applicable, randomized controlled trials may provide the required quality of data, especially when pilot programmes are being initiated. However, in health systems research, the use of randomized controlled trials is often not possible. In absence of pilot programmes, before and after, quasi-experimental designs and interrupted time-series studies with some equivalent control sites could be an alternative. Finally, another priority area for research is policy analysis to evaluate options for the financing of health services. In each case, careful documentation of barriers and facilitators to implementation is required, with special attention to the role of context (private versus public sector, prevailing socio-economic situation, urban versus rural, etc.). Thus, both qualitative and quantitative studies could play a role in generating evidence for scaling up of the lessons learnt
Sources of support: Not applicable
Acknowledgements: Not applicable
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This document should be cited as: Waiswa WP. The impact of user fees on access to health services in low- and middle-income countries: RHL commentary (last revised: 1 May 2012). The WHO Reproductive Health Library; Geneva: World Health Organization.