The impact of user fees on access to health services in low- and middle-income countries

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.

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.

Read the full abstract...

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.


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.