Bulletin of the World Health Organization

The impact of user fees on health service utilization in low- and middle-income countries: how strong is the evidence?

Mylene Lagarde, Natasha Palmer

Volume 86, Number 11, November 2008, 839-848

Table 10. Effects of increasing user fees on health service utilization in low- and middle-income countries, according to literature review

Study Outcome measure Percent variation in fee Reanalysis for the systematic review
Conclusions presented in the original study
Percent change in intervention area(s) “Absolute” elasticity Percent change in control area(s) Percent change in intervention areas “Relative” elasticity
Issifou & Kremsner (2004)34 Number of outpatient visits +66 –47.4*** –0.7 –13.3 –34.1 –0.5 Drop in use in both cases
+20a –44.5*** –2.2 +26.9 –71.4 –3.6

Bratt et al. (2002)30 Average number of visits to obsetrician-gynaecologist +35.6 –22.5 –0.63b –16.7 –5.8 –0.32c Decrease in use but inelastic demand (for all cases)
+53.5 –25.9 –0.48b 16.7 –9.3 –0.26c
Average number of prenatal visits +36.9 –5.0 –0.14b –3.0 –2.0 –0.10c
+54.6 –13.4 –0.25b –3.0 –10.4 –0.28c

Significance levels (computed for the review when possible): ***P < 0.001.a The second increase of 20% took place after the first increase of 66%.b Unlike Bratt et al.30 who computed arc elasticities using the “mid-point technique”, arc elasticities were recomputed using the following formula: (QF–QI) / QI / (PF–PI) / PI, to use a coherent method throughout the review.c Control areas experienced changes in price as well, even though they were less important: +17.4% for visits to obstetrician-gynaecologist, +17% for prenatal visits, +18.5% for intrauterine device (IUD) insertions and +17.5% for IUD revisits.

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