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 9. Effects of reducing 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)a “Absolute” elasticitya Percent change in control area(s) Percent change in intervention areas “Relative” elasticity
Abdu et al. (2004)31 Number of children seen in health centres for malaria –25 +63.6*** –2.5 +31 +32.6 –1.3 Increase in use of services; lesser increase in facilities offering 50% exemption perhaps due to lack of health personnel
–50 +32.3*** –0.6 +31 +1.3 –0.02
–75 +280.4*** –3.7 +31 +249.4 –3.3
Number of pregnant women seen in health centres for malaria –25 +52.1*** –2.1 +6.2 +45.9 –1.8
–50 +27.9*** –0.6 +6.2 +21.7 –0.43
–75 +131.4*** –1.7 +6.2 +125.2 –1.7

Ojeda et al. 199428 Number of monthly new IUD usersb –25 +254.8*** –10.2 +72.6 +182.2 –7.3 Increase in the number of users
–50 +287.3*** –5.7 +72.6 +214.7 –4.3
–25 +236.5*** –9.5 +30.8 +205.7 –8.2
–50 +241.2*** –4.8 +30.8 +210.5 –4.2

Significance levels (computed for the review when possible): ***P < 0.001.IUD, intrauterine device.a In the original paper by Abdu et al.,31 this is defined as the “correlation coefficient between the level of exemption and relative increase of cases of malaria seen”.b The first two rows compare changes between the period September 1991–February 1992 and September 1992–February 1993, while the last two compare the periods of March–August 1992 and March–August 1993.

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