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 6. Main characteristics of studies on increasing 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
Bennett (1989)33 Lesotho – 4 district hospitals and 3 private not-for-profit (controls from a unique district) ITSa Increase of user fees in PHC facilities with some control data Limited data (weekly series over 1 year) cannot account for seasonal variations; no information on contextual factors; intervention and control sites not equivalent; use of routine data, potentially unreliable; data reanalysed to account for their longitudinal nature High

Issifou & Kremsner (2004)34 Gabon – a private (for profit) hospital and a public one (control) CBA Increase of consultation fees in a private hospital Non-equivalence of intervention and control sites; use of routine data, potentially unreliable; data reanalysed to account for their longitudinal nature High

Bratt et al. (2002)30 Ecuador – 5 blocks of 3 clinics each (each block has 2 treatment sites and 1 control) C-RCT Increase of user fees for reproductive health services in private not-for-profit clinics – pilot study Limited number of clusters; clustering effects mentioned (and controlled for) in only one analysis; discrepancies between control and intervention groups; biased sample (clinics’ patients are better off than national average) High

CBA, controlled “before and after”; C-RCT, cluster randomized controlled trial; ITS, interrupted time series; PHC, primary health care.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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