The impact of user charges on health outcomes in low-income and middle-income countries: a systematic review. BMJ global health BACKGROUND:User charges are widely used health financing mechanisms in many health systems in low-income and middle-income countries (LMICs) due to insufficient public health spending on health. This study systematically reviews the evidence on the relationship between user charges and health outcomes in LMICs, and explores underlying mechanisms of this relationship. METHODS:Published studies were identified via electronic medical, public health, health services and economics databases from 1990 to September 2017. We included studies that evaluated the impact of user charges on health in LMICs using randomised control trial (RCT) or quasi-experimental (QE) study designs. Study quality was assessed using Cochrane Risk of Bias and Risk of Bias in Non-Randomized Studies-of Intervention for RCT and QE studies, respectively. RESULTS:We identified 17 studies from 12 countries (five upper-middle income countries, five lower-middle income countries and two low-income countries) that met our selection criteria. The findings suggested a modest relationship between reduction in user charges and improvements in health outcomes, but this depended on health outcomes measured, the populations studied, study quality and policy settings. The relationship between reduced user charges and improved health outcomes was more evident in studies focusing on children and lower-income populations. Studies examining infectious disease-related outcomes, chronic disease management and nutritional outcomes were too few to draw meaningful conclusions. Improved access to healthcare as a result of reduction in out-of-pocket expenditure was identified as the possible causal pathway for improved health. CONCLUSIONS:Reduced user charges were associated with improved health outcomes, particularly for lower-income groups and children in LMICs. Accelerating progress towards universal health coverage through prepayment mechanisms such as taxation and insurance can lead to improved health outcomes and reduced health inequalities in LMICs. TRIAL REGISTRATION NUMBER:CRD 42017054737. 10.1136/bmjgh-2018-001087

The impact of user fees on health service utilization in low- and middle-income countries: how strong is the evidence? Lagarde Mylene,Palmer Natasha Bulletin of the World Health Organization OBJECTIVE:To assess the effects of user charges on the uptake of health services in low- and middle-income countries. METHODS:A systematic search of 25 social science, economics and health literature databases and other sources was performed to identify and appraise studies on the effects of introducing, removing, increasing or reducing user charges on the uptake of various health services in low- and middle-income countries. Only experimental or quasi-experimental study designs were considered: cluster randomized controlled trials (C-RCT), controlled " before and after" (CBA) studies and interrupted time series (ITS) studies. Papers were assessed in which the effect of the intervention was measured in terms of changes in service utilization (including equity outcomes), household expenditure or health outcomes. FINDINGS:Sixteen studies were included: five CBA, two C-RCT and nine ITS. Only studies reporting effects on health service utilization, sometimes across socioeconomic groups, were identified. Removing or reducing user fees was found to increase the utilization of curative services and perhaps preventive services as well, but may have negatively impacted service quality. Introducing or increasing fees reduced the utilization of some curative services, although quality improvements may have helped maintain utilization in some cases. When fees were either introduced or removed, the impact was immediate and abrupt. Studies did not adequately show whether such an increase or reduction in utilization was sustained over the longer term. In addition, most of the studies were given low-quality ratings based on criteria adapted from those of the Cochrane Collaboration's Effective Practice and Organisation of Care group. CONCLUSIONS:There is a need for more high-quality research examining the effects of changes in user fees for health services in low- and middle-income countries. 10.2471/blt.07.049197

The impact of user fees on access to health services in low- and middle-income countries. The Cochrane database of systematic reviews BACKGROUND:Following an international push for financing reforms, many low- and middle-income countries introduced user fees to raise additional revenue for health systems. User fees are charges levied at the point of use and are supposed to help reduce 'frivolous' consumption of health services, increase quality of services available and, as a result, increase utilisation of services. OBJECTIVES:To assess the effectiveness of introducing, removing or changing user fees to improve access to care in low-and middle-income countries SEARCH STRATEGY:We searched 25 international databases, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group's Trials Register, CENTRAL, MEDLINE and EMBASE. We also searched the websites and online resources of international agencies, organisations and universities to find relevant grey literature. We conducted the original searches between November 2005 and April 2006 and the updated search in CENTRAL (DVD-ROM 2011, Issue 1); MEDLINE In-Process & Other Non-Indexed Citations, Ovid (January 25, 2011); MEDLINE, Ovid (1948 to January Week 2 2011); EMBASE, Ovid (1980 to 2011 Week 03) and EconLit, CSA Illumina (1969 - present) on the 26th of January 2011. SELECTION CRITERIA:We included randomised controlled trials, interrupted time-series studies and controlled before-and-after studies that reported an objective measure of at least one of the following outcomes: healthcare utilisation, health expenditures, or health outcomes. DATA COLLECTION AND ANALYSIS:We re-analysed studies with longitudinal data. We computed price elasticities of demand for health services in controlled before-and-after studies as a standardised measure. Due to the diversity of contexts and outcome measures, we did not perform meta-analysis. Instead, we undertook a narrative summary of evidence. MAIN RESULTS:We included 16 studies out of the 243 identified. Most of the included studies showed methodological weaknesses that hamper the strength and reliability of their findings. When fees were introduced or increased, we found the use of health services decreased significantly in most studies. Two studies found increases in health service use when quality improvements were introduced at the same time as user fees. However, these studies have a high risk of bias. We found no evidence of effects on health outcomes or health expenditure. AUTHORS' CONCLUSIONS:The review suggests that reducing or removing user fees increases the utilisation of certain healthcare services. However, emerging evidence suggests that such a change may have unintended consequences on utilisation of preventive services and service quality. The review also found that introducing or increasing fees can have a negative impact on health services utilisation, although some evidence suggests that when implemented with quality improvements these interventions could be beneficial. Most of the included studies suffered from important methodological weaknesses. More rigorous research is needed to inform debates on the desirability and effects of user fees. 10.1002/14651858.CD009094

Influencing factors of inequity in health services utilization among the elderly in China. Fu Xianzhi,Sun Nan,Xu Fei,Li Jin,Tang Qixin,He Junjian,Wang Dongdong,Sun Changqing International journal for equity in health BACKGROUND:With the rise of the aging population, it is particularly important for health services to be used fairly and reasonably in the elderly. This study aimed to assess the present inequality and horizontal inequity for health service use among the elderly in China and to identify the main determinants associated with the disparity. METHODS:This cross-sectional study was based on the sample of the survey of the China Health and Retirement Longitudinal Study (CHARLS) for 2015. The elderly was defined as individuals aged 60 and above, with a total of 7836 participants. We used the concentration index (CI) and the horizontal inequity (HI) to measure the inequity of the utilization of health services. The method of concentration index decomposition was utilized to measure the contribution of various influential factors to the overall unfairness. RESULTS:The CI for the probability and the frequency of outpatient use were 0.1102 and 0.1015, respectively, and the corresponding values of inpatient use were 0.2777 and 0.2980, respectively. The household consumption expenditure disparity was the greatest inequality factor favoring the better-off. The Urban Employee Basic Medical Insurance made a pro-wealth contribution to inequality in frequency of health services utilization (17.58% for outpatient and 13.40% for inpatient). The contributions of New Rural Cooperative Medical Scheme on reducing unfairness in inpatient use were limited (- 2.23% for probability of inpatient use and - 5.89% for frequency of inpatient use). CONCLUSIONS:There was a strong pro-rich inequality in both the probability and the frequency of use for health services among the elderly in China. The medical insurance was not enough to address this inequity, and different medical insurance schemes had different effects on the unfairness of health service utilization. 10.1186/s12939-018-0861-6