Systematic Review of Effects of User Fees on Uptake of Services in Low- and Middle-Income Countries

This very thorough systematic review screened no less than 24,125 studies reported among 25 databases, but only 16 studies survived the screening process.[1] They were mostly interrupted time series studies, with five controlled before-and-after studies and two cluster experimental studies also. Five studies were concerned with introduction of user fees when none previously existed, and three examined the effect of increasing user fees. The findings show that:

  1. User fees cause a marked reduction in utilisation of curative services, suggesting that demand is elastic to changes in price.
  2. The effect is immediate and does not appear to ‘recover’.
  3. The above effect appears to be less sensitive for preventive services, but this is based on one study only.

The statistical analysis is elegant, comparing slopes (not just mean values) before and after changing fee policy and allowing for any autocorrelation. These study results have been replicated in a systematic review of ‘co-payments’ in high-income countries [2] and are consistent with the model proposed in a previous post.[3]

— Richard Lilford, CLAHRC WM Director


  1. Lagarde M & Palmer N. The impact of user fees on health service utilization in low- and middle-income countries: how strong is the evidence? Bull World Health Organ. 2008; 86(11): 839-48.
  2. Kiil A, & Houlberg K. How does copayment for health care services affect demand, health and redistribution? A systematic review of the empirical evidence from 1990 to 2011. Eur J Health Econ. 2014; 15: 813-28.
  3. Lilford R. User Fees and Co-Payments: The Evidence Accumulates. NIHR CLAHRC West Midlands News Blog. 25 Sept 2015.

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