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 8. Effects of introducing (or increasing) user feesa on health service utilization in low- and middle-income countries, according to literature review

Study Outcome measure (monthly averages) Reanalysis for the systematic review
Conclusions presented in the original study
Trend before change (β1) at intervention sitesb Trend before (β1) at control sitesb Immediate effect of intervention (β2) at intervention sitesb Immediate effect of intervention (β2) at control sitesb Trend after change (β3) at intervention sitesb Trend after change (β3) at control sitesb
Ridde (2003)20 Use of curative services – new consultationsc –15.77 (20.80) –11.84* (5.60) –135.56 (447.29) 134.35 (126.02) –6.60 (17.65) 6.17 (4.73) Drop in use in intervention sites versus increase in control sites (no statistical test)

Mbugua et al. (1995)21 Use of curative services in hospitals and health centres (intervention)c and in dispensaries (controls) – new consultations –269.48 (140.66) –221.67* (867.15) –2 916.4* (1 354.24) 2 157.1* (867.15) 266.42 (140.66) 189.40* (88.35) Drop in use in intervention sites versus increase in control sites (no statistical test)

Collins et al. (1996)22 Use of curative services – general outpatient visits in district hospitals –111.05 (36.44)** NA –2 225.8** (351.6) NA 61.18 (49.35) NA Drop in use in both intervention sites
Use of curative services – general outpatient visits in provincial hospitals –3.78 (68.3) NA –5 920.7** (658.7) NA –2.30 (92.5) NA

Moses et al. (1992)24 Use of curative services – new visits by womenc –11.97 (7.58) NA –644.02*** (186.72) NA 40.33 (29.36) NA Sharp decline in use, more striking for men than women
Use of curative services – new visits by menc –33.69*** (9.56) NA –1 221.7* (232.15) NA –15.68 (36.64) NA

Benjamin et al. (2001)23 Use of antenatal services – new enrolees 5.71*** (2.07) –6.16*** (1.71) –67.71 (43.36) 106.08*** (35.93) –0.65 (2.35) –2.79 (1.94) Immediate drop in use, then increase

Bennett (1989)33,d Use of curative services – outpatient visits by all age groupsc –2.68 (2.03) –2.67 (1.47) –167.10** (43.22) –7.32 (29.90) –0.37 (2.03) –0.14 (1.47) Significant drop in use in all facilitiese (differences in means)

*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.b Values in parentheses are standard errors.c The analysis corrected for auto-correlation in the data series.d Unlike all other studies in the table, this one refers to an increase in user fees.e For the reanalysis, only the results on the average utilization rates in 4 intervention facilities versus average utilization rate in the 2 control sites are presented. Reanalysis at the facility level showed a similar significant drop in utilization in 3 out of 4, while the small observed changes in the control sites were not significant.

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