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 7. Effects of abolishing user feesa on health service utilization in low- and middle-income countries, according to literature review

Study Outcome measureb (monthly averages) Reanalysis for the systematic review
Conclusions presented in the original study
Trend before change (β1) at intervention sites Trend before (β1) at control sites Immediate effect of intervention (β2) at intervention sites Immediate effect of intervention (β2) at control sites Trend after change (β3) at intervention sites Trend after change (β3) at control sites
Burnham et al. (2004)25 Use of curative services – new visits by patients < 5 years –107.31 (219.2) NA 4 131.31* (1 240.78) NA –40.00 (105.31) NA Increased use of curative services, less important among young children; increased use of all preventive services (not tested)
Use of curative services – new visits by all patients 749.83 (665.1) NA 14 190.95* (3 777.56) NA 136.23 (312.12) NA
Use of preventive services – immunizations –763.79 (408.53) NA 3 975.45 (2 283.6) NA 416.61** (201.45) NA
Use of preventive services – antenatal care visits –89.21 (103.33) NA 966.43 (586.93) NA 148.80*** (48.42) NA
Use of preventive services – family planning visits –30.22 (20.60) NA 138.13 (166.60) NA 56.60*** (9.89) NA

Nabyonga et al. (2005)35 Use of preventive services – 1st antenatal care visits 0.11 (0.84) –0.05 (0.44) –6.21 (8.55) –4.43 (4.47) 0.86 (0.42) 0.21 (0.23) No change in either outcome variable (not tested)
Use of curative services – inpatient admissions 3.85 (2.28) 0.55 (4.15) –42.24 (22.15) –29.31 (41.72) 2.63** (1.20) 2.74 (2.13)

Moses et al. (1992)24 Use of curative services – new visits by women, monthly average 37.07 (65.05) NA 434.74 (353.37) NA 40.88 (34.89) NA Sharp increase in visits, in particular for men (not tested)
Use of curative services – new visits by men –4.21 (32.67) NA 510.56** (188.51) NA 16.95 (16.86) NA

Collins et al. (1996)22 Use of curative services – general outpatient visits in district hospitals 61.2 (69.2) NA 1 499.37* (399.3) NA 41.5** (15.8) NA Sharp increase in use in both intervention sites
Use of curative services – general outpatient visits in provincial hospitals –2.31 (116.4) NA 3 481.6*** (671.8) NA –109.3*** (26.6) NA

Wilkinson et al. (2001)26 Use of curative services – visits by adults 40.15 (19.69) NA 399.13** (166.52) NA 58.72** (20.12) NA Increase in curative services uptake; gradual fall in preventive service uptake in children and pregnant women
Use of preventive services (immunization and growth monitoring) – visits by children < 6 years –63.73 (33.83) NA 272.42 (277.06) NA –33.57 (34.99) NA
Use of preventive services – antenatal care visits –17.53 (12.98) NA 298.56** (109.77) NA –24.62 (13.26) NA

*P < 0.05; **P < 0.01; ***P < 0.001.NA, not applicable (denotes the absence of control sites in the original study).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. See method section for further details.b The analysis corrected for auto-correlation in the data series.c Values in parentheses are standard errors.

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