Table 3.
Summary of the impact of user charges on certain health outcomes and secondary outcomes
| Study | Intervention | Population | Improved general health | Improved mortality outcomes | Improved infectious disease– related outcomes |
Improved chronic disease– related outcomes |
Improved nutritional outcomes | Increased access to primary care or outpatient | Increased access to secondary care | Increased access to tertiary care or inpatient | Improved financial protection | Notes | Study quality |
| Decreased user charges | |||||||||||||
| Nguyen and Wang26 | Before: user fees in the public hospitals were a major financial burden After: free care including inpatient and outpatient services, and associated laboratory tests and generic medicines |
Vietnam—non-poor children under 6 years old | ↑ | – | – | – | – | – | ↑ | ↓ | ↑ | There was a ‘substitution’ effect between increased use of secondary hospitals and decreased use of tertiary hospitals | High |
| Sood and Wagner24 | Before: unspecified After: no premiums or copayments at the point of tertiary care at both private and public hospitals in 2010–2012 |
India— poor population |
↑ | – | ↑ | – | – | – | – | ↑ | – | There was a ‘substitution’ effect between increased use of tertiary care and readmission | Moderate |
| Beuermann23 | Before: pay out-of-pocket fees (amount unspecified) After: no user fee for healthcare services (ie, doctor’s consultation, diagnosis, surgeries) |
Jamaica— general population |
↑ | – | – | – | – | – | – | – | – | Improved general health had a positive labour supply effect with increased labour hours | Moderate |
| Bauhoff et al 27 | Before: unspecified After: comprehensive benefit package with few coverage limits and no copayments for beneficiaries; basic universal package subjected to copayments of 25%–50% for non-MIP population |
Georgia— poor population |
→ | – | – | – | – | → | – | → | ↑ | The reduction of user charges provided financial protection, but little impact on service use and self-reported health status | Moderate |
| Guindon25 | Before: unspecified After: no deductibles for most outpatient and inpatient care at government facilities and drugs on the Ministry of Health list, financed from general government revenues at both national (75%) and provincial (25%) levels |
Vietnam— poor population |
→ | – | – | – | – | → | – | ↑ | – | Low | |
| Aggarwal29 | Before: full cost for treatment After: free outpatient diagnosis for all types of medical events and up to 50% discount on all laboratory tests |
India—disadvantaged rural general population | ↑ | – | – | – | – | ↑ | – | ↑ | ↑ | The author suggested that decreased user charges increased access to healthcare services and improved financial protection, which should translate into better health outcomes | Moderate |
| Yiqiu Wang et al 28 | Before: unspecified After: out-of-pocket reduced 26%–35% (covered service not specified) |
China— rural general population (age 12 year and above) |
→ | – | – | – | – | ↓ | ↑ | – | → | Low | |
| Nguyen and Lo Sasso30 | Before: unspecified After: free care at public facilities for inpatient and outpatient services (excluding non-prescription medicines) |
Vietnam— children under age of 6 |
↑ | – | – | – | – | ↑ | – | ↑ | → | Moderate | |
| Sood et al 40 | Before: unspecified After: free tertiary care at the point of service in both private and public hospitals |
India— poor population |
– | ↑ | – | – | – | – | – | ↑ | ↑ | Both increased access to healthcare and reduced out-of-pocket expenditure might have contributed to reduction in mortality | Moderate |
| Ansah et al 39 | Before: unspecified After: free primary care, drugs and initial secondary care on moderate anaemia |
Ghana— rural children age under 5 |
– | → | → | → | – | ↑ | – | – | – | Increased primary care use did not improve health. A possible reason could be that user fees may not be the major financial barrier to care | High |
| McKinnon et al 41 | Before: unspecified After: free deliveries in public, private and facility-based health facilities, covering all normal deliveries, management of assisted deliveries including caesareans, and management of medical and surgical complications of delivery (Ghana) Free deliveries in all public dispensaries and health centres, including all supplies required for delivery. The policy did not initially cover delivery fees in district hospitals and thus did not apply to caesarean sections (Kenya) Covers normal deliveries at health posts and health centres and caesarean sections at district and regional hospitals (Senegal) |
Multi-African countries— women |
– | ↑ | – | – | – | – | ↑ | – | – | Removing user fees increased facility-based deliveries and contributed to reduction in neonatal mortality | Moderate |
| Lamichhane et al 32 | Before: unspecified After: free delivery at public facilities |
Nepal—women (15–49 years old) | – | ↑ | – | – | – | – | ↑ | – | – | Reduction in mortality was consistent with the increased use of skilled birth assistance and public facilities for delivery | High |
| Quimbo et al | Before: 49% of total health expenditure paid out-of-pocket After: increase peso ceilings to eliminate copayment for hospitalisation |
Philippines— poor children |
– | – | ↑ | – | ↑ | – | – | – | – | Low | |
| Rivera-Henandez et al | Before: unspecified After: remove copayment for crucial healthcare services for diagnosis and treatment of diabetes and hypertension |
Mexico—poor population aged 50 and above | – | – | – | ↑/→ | – | ↑ | – | – | – | Moderate | |
| Sosa-Rubi et al 42 | Before: unspecified After: no copayment for specific type of healthcare received |
Mexico— poor population (aged 20–80 years) |
– | – | – | ↑ | – | ↑ | ↑ | – | – | Decreased user charges increased access to healthcare and improve blood glucose level control | Moderate |
| Tanaka44 | Before: unspecified After: free services to pregnant women included prenatal and postnatal care from confirmation of pregnancy until 42 days after delivery, and all health services to children under 6 years old became free |
South Africa—poor women and children under 6 years old | – | – | – | – | ↑ | – | – | – | – | Improved child health status was through increased access to health services | High |
| Increased user charges | |||||||||||||
| Huang and Gan31 | Before: Outpatient care: around 30%–40% of total health expenditure were paid out-of-pocket. Inpatient care: around 20% of total health expenditure were paid out-of-pocket After: Outpatient care: around 86% of total expenditure were paid out-of-pocket Inpatient care: around 28% of total health expenditure were paid out-of-pocket |
China— urban general employees |
→ | – | – | – | – | ↓ | – | → | – | Increased user charges decreased outpatient use and expenditure but not for inpatient use and expenditure, and health outcomes | Low |
→, not statistically significant change; ↓, negative change; ↑, beneficial effect on health or increased use/expenditure.