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 3. Main characteristics of studies on the introduction of user fees and its effects on health service utilization in low- and middle-income countries, according to literature review

Study Study setting Study design Intervention Quality assessment Overall risk of bias
Ridde (2003)20 Burkina Faso – 9 intervention and 5 control health centres ITSa Introduction of user fees in PHC facilities compared with some control facilities. National policy change Presence of confounding factors; differences in control and treatment groups; time of intervention varied slightly across facilities; use of routine data, potentially unreliable; data reanalysed to account for their longitudinal nature High

Mbugua et al. (1995)21 Kenya – 1 hospital and 2 health centres and 3 free dispensaries (control) ITSa Introduction of user fees in hospitals and health centres. National policy change Presence of confounding factors; few observation points; control sites not equivalent; use of routine data, potentially unreliable; data reanalysed to account for their longitudinal nature High

Collins et al. (1996)22 Kenya – 4 district hospitals and 3 provincial hospitals ITSa Introduction of user fees in hospitals and health centres. National policy change Presence of confounding factors (economic hardship); few observation points; use of routine data, potentially unreliable; data reanalysed to account for their longitudinal nature High

Moses et al. (1992)24 Kenya – Nairobi’s special treatment clinic for STIs ITSa Introduction of user fees in the national referral structure for STIs. National policy change Presence of confounding factors; few observations after the intervention; specific to one referral centre for STIs; use of routine data, potentially unreliable; data reanalysed to account for their longitudinal nature High

Benjamin et al. (2001)23 Papua New Guinea – 1 general hospital and urban clinics (controls) ITSa Introduction of user fees for antenatal care in a hospital. National policy change Presence of confounding factors; potential secular changes; use of routine data, potentially unreliable; data reanalysed to account for their longitudinal nature High

Kremer & Miguel (2007)32 Kenya – 75 schools (25 randomly selected to introduce cost recovery) C-RCT Introduction of user fees for preventive deworming drugs. Experimental study Slight difference in time of pre-intervention exposure to free drugs between some control and intervention sites Low

Diop et al. (1995)29 Niger – primary care facilities in 3 districts (2 intervention sites, 1 control) CBA Introduction of user fees + quality improvements in PHC facilities. Pilot study Differences in control and intervention sites (potentially affecting health-seeking behaviours); pre-existence of informal fees in the control sites; statistical analysis not always appropriate High

Litvack & Bodart (1993)4 Cameroon – 5 health centres (2 control, 3 intervention) CBA Introduction of user fees + quality improvements in PHC facilities. Pilot study Selection of control and treatment facilities unclear; no details provided on characteristics of treatment and control sites; statistical analysis not always appropriate (failure to test for statistical significance of comparisons; inappropriate econometric analysis of variations across socioeconomic groups) High

CBA, controlled “before and after”; C-RCT, cluster randomized controlled trial; ITS, interrupted time series; PHC, primary health care; STIs, sexually transmitted infections.a Longitudinal data were reanalysed by the authors of the review, so that the results do not necessarily reflect the conclusions and views of the authors of the original paper.

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