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Lagarde, M; Palmer, N (2011)
Publisher: Cochrane Collaboration
Languages: English
Types: Article
: 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 services.
: To assess the effectiveness of introducing, removing or changing user fees to improve access to care in low-and middle-income countries
: 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.
: 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.
: 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 evidence.
: 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.
: 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 utilisation 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 beneficial. 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.
  • The results below are discovered through our pilot algorithms. Let us know how we are doing!

    • The search to identify studies for this review was initially done as a part of a much wider review on health financing mechanisms (Lagarde 2006) dealing with the effects of several financing strategies. The broad review has been split into several sub-reviews, including the present one. Therefore the search methodology includes terms that encompass a broader scope that the one defined for this review.
    • 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 nd relevant grey literature.
    • We originally searched the following electronic databases without language or date restrictions: • The Cochrane EPOC Group Trials Register (and the database of studies awaiting assessment), 20/01/2006 • The Cochrane Central Register of Controlled Trials (CENTRAL) The Cochrane Library, 20/01/2006 • MEDLINE, 11/11/2005 • EMBASE (Athens), 19/04/2006 • Popline, 08/12/2005 • African Healthline (bibliographic databases on African health issues), 28/04/2006 • IBSS (International Bibliography in Social Sciences, Athens interface), 19/04/2006 • The Database of Abstracts of Reviews of Effectiveness, 20/ 01/2006 • BLDS, 03/11/2005 • ID21, 24/11/2005 • ELDIS, 25/11/2005 • The Antwerp Institute of Tropical Medicine database, 26/ 01/2006 • Jstor, 26/01/2005 • Inter-Science (Wiley), 16/12/2005 • ScienceDirect, 16/12/2005 • IDEAS(Repec), 20/01/2005 • LILACS, 19/04/2006 • CAB-Direct (Global Health), 17/04/2006 • Healthcare Management Information Consortium (HMIC), 17/04/2006 • World Health Organization Library Information System (WHOLIS), 18/04/2006 • MEDCARIB, 19/04/2006 • ADOLEC, 19/04/2006 • FRANCIS, 16/12/2005 • BDSP, 16/12/2005 • USAID database, 04/11/2005.
    • We developed the MEDLINE search strategy mainly using reviews cited in the background section of the protocol (Lagarde 2006) and their references. The strategy includes terms for the following types We performed an updated search of the following databases on January 26, 2011: • The Cochrane Central Register of Controlled Trials (CENTRAL DVD-ROM) 2011, Issue 1, part of the The Cochrane Library.www.thecochranelibrary.com • 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) • EconLit, CSA Illumina (1969 - present) R E S U L T S O F Ridde 2003 {published data only} Ridde V. Fees-for-services, cost recovery, and equity in a district of Burkina Faso operating the Bamako Initiative. Bulletin of the World Health Organization 2003; Vol. 81, issue 7:532-8.
    • Wilkinson 2001 {published data only} Wilkinson D, Gouws E, Sach M, Karim SS. Effect of removing user fees on attendance for curative and preventive primary health care services in rural South Africa. Bulletin of the World Health Organization 2001; Vol. 79, issue 7: 665-71.
    • References to studies excluded from this review Akashi 2004 {published data only} Akashi H, Yamada T, Huot E, Kanal K, Sugimoto T. User fees at a public hospital in Cambodia: effects on hospital performance and provider attitudes. Social Science and Medicine 2004;58(3):553-64.
    • Cohen 2010 {published data only} Cohen J, Dupas P. Free distribution or cost-sharing? Evidence from a randomized malaria prevention experiment. Quarterly Journal of Economics 2010;125(1):1-45.
    • Deininger 2005 {published data only} Deininger K, Mpuga P. Economic and welfare Impact of the abolition of health user fees: evidence from Uganda. Journal of African Economies 2005;14(1):55-91.
    • Ellis 1994 {published data only} Ellis RP, Chawla M. Demand side impacts: Experiment in health care cost recovery in Niger. Bethesda, MD: Abt Associates, 1994.
    • Jacobs 2004 {published data only} Jacobs B Price N. The impact of the introduction of user fees at a district hospital in Cambodia. Health Policy and Planning 2004;19(5):310-21.
    • Leighton 1994 {published data only} Leighton C, Becker G, Yann D, Laurin E. Review of cost recovery experience in the Central African Republic. Health Systems 20/20. Partners for Health Reformplus (PHRplus), 1994.
    • Levy-Bruhl 1997 {published data only} Levy-Bruhl D, Soucat A, Osseni R, Ndiaye JM, Dieng B, De Bethune X, et al.The Bamako Initiative in Benin and Guinea: improving the effectiveness of primary health care. International Journal of Health Planning and Management 1997;12 Suppl 1:S49-79.
    • Matee 2000 {published data only} Matee M, Simon E. Utilisation of dental services in Tanzania before and after the introduction of cost-sharing. International Dental Journal 2000;50(2):69-72.
    • Mpuga 2002 {published data only} Mpuga Paul. Health outcomes after the abolition of Costsharing in public hospitals in Uganda. Johannes Kepler University, Linz 2002.
    • Osuga 1993 {published data only} Osuga B, Nordberg E. Effects of new service charges on attendance at rural health facilities in Kenya. East African Medical Journal 1993;70(10):627-31.
    • Soucat 1997 {published data only} Soucat A, Levy-Bruhl D, De Bethune X, Gbedonou P, Lamarque JP, Bangoura O, et al.Affordability, costeffectiveness and efficiency of primary health care: the Bamako Initiative experience in Benin and Guinea. International Journal of Health Planning and Management 1997;12 Suppl 1:S81-108.
    • Willis 1995 {published data only} Willis CY, Leighton C. Protecting the poor under cost recovery: the role of means testing. Health Policy and Planning 1995;10(3):241-56.
    • Wouters 1995 {published data only} Wouters A. Improving quality through cost recovery in Niger. Health Policy and Planning 1995;10(3):257-70.
    • Xu 2006 {published data only} Xu K, Evans D, Kadama P, Nabyonga J, Ogwal PO, Nabukhonzo P, et al.Understanding the impact of eliminating user fees: utilization and catastrophic health expenditures in Uganda. Social Science and Medicine 2006; 62:866-76.
    • Yazbeck 1994 {published data only} Yazbeck AS, Wenner M. Social financing and fee-for-service cost recovery in Niger: field work, research results and policy recommendations. Health Systems 20/20. Bethesda, MD: Abt Associates, 1994.
    • Yazbeck 1995 {published data only} Yazbeck A, Leighton C. Research note: does cost recovery for curative care affect preventive care utilization?. Health Policy and Planning 1995;10(3):296-300.
    • Yoder 1989 {published data only} Yoder RA. Are people willing and able to pay for health services?. Social Science and Medicine 1989;29(3):35-42.
    • Akin 1986 Akin J, Griffin C, Guilkey DK, Popkin BM. The demand for adult outpatient services in the Bicol region of the Philippines. Social Science and Medicine 1986; Vol. 22, issue 3:321-8.
    • Barnum 1993 Barnum H, Kutzin J. Public Hospitals in developing countries: resource use, cost, financing. Public Hospitals in Developing Countries: Resource Use, Cost, Financing. Baltimore: Johns Hopkins University Press, 1993.
    • Commission 2005 Commission for Africa. Our Common Interest: Report of the Commission for Africa. http://www.cfr.org/africa/ our-common-interest-report-commission-africa/p8292. London: Commission for Africa, 2005.
  • No related research data.
  • No similar publications.

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