Researchers in the Cochrane Collaboration conducted a review of the impact of user fees on people’s access to health services in low- and middle-income countries. After searching for all relevant studies, they found 16 studies. Their findings are summarised below.
User fees and people’s use of health services
In many countries, people may have to pay a charge, or user fee, for their health services, for instance when visiting the doctor or receiving drugs and other medical supplies.
User fees were introduced in many low- and middle-income countries in the 1980s with the support of UNICEF and the World Bank. A number of reasons were given for the introduction of these fees. One argument is that user fees are expected to stop people from seeking unnecessary health care. They are also seen as a way to raise extra funds that can be used to improve the quality of health services. These extra funds can also be used to expand health services and ensure that the whole population gets access to health care.
Critics have, however, argued that the introduction of user fees prevents poor people from using necessary health services. Recently, several campaigns have advocated the removal of user fees, especially for primary care.
What happens when user fees are introduced or removed?
The studies in this review took place in 12 different countries. They evaluated either the effects of introducing user fees; removing fees; or increasing or decreasing fees. The studies varied according to the type of health services and the level and nature of payment. While some of the studies looked at the impact of large-scale national reforms, other studies looked at small-scale pilot projects.
All of the evidence was of very low quality and the studies showed mixed results:
When user fees were introduced or increased:
- People’s use of preventive healthcare services decreased.
- People’s use of curative services generally decreased. However, when quality improvements were made to the health services at the same time as fees were introduced, people’s use of curative services increased. In addition, poor parts of the population began to use health care services more.
When user fees were removed:
- There was usually no immediate impact on people’s use of preventive healthcare services. But in several cases, people’s use of these services did increase after some time.
- There was some increase in the number of outpatient visits, but no increase in the number of inpatient visits.
When user fees were decreased:
- There was an increase in the use of preventive and curative healthcare services, ranging from a very small to a large increase.
To summarise, results were mixed and the quality of the evidence was very low. We are therefore uncertain about the effects of user fees on health service use.