Impact Of User Fees Research Articles

Erratum to: The impact of user fees on health services utilization and infectious disease diagnoses in Neno District, Malawi: a longitudinal, quasi-experimental study.

User fees have generally fallen out of favor across Africa, and they have been associated with reductions in access to healthcare. We examined the effects of the introduction and removal of user fees on outpatient attendances and new diagnoses of HIV, malaria, and tuberculosis in Neno District, Malawi where user fees were re-instated at three of 13 health centres in 2013 and subsequently removed at one of these in 2015. We conducted two analyses. Firstly, an unadjusted comparison of outpatient visits and new diagnoses over three periods between July 2012 and October 2015: during the period with no user fees, at the re-introduction of user fees at four centres, and after the removal of user fees at one centre. Secondly, we estimated a linear model of the effect of user fees on the outcome of interest that controlled for unobserved health centre effects, monthly effects, and a linear time trend. The introduction of user fees was associated with a change in total attendances of −68 % [95 % CI: −89 %, −12 %], similar reductions were observed for new malaria and HIV diagnoses. The removal of user fees was associated with an increase in total attendances of 352 % [213 %, 554 %] with similar increases for malaria diagnoses. The results were not sensitive to control group or model specification. User fees for outpatient healthcare services present a barrier to patients accessing healthcare and reduce detection of serious infectious diseases.

The impact of user fees on health services utilization and infectious disease diagnoses in Neno District, Malawi: a longitudinal, quasi-experimental study.

BackgroundUser fees have generally fallen out of favor across Africa, and they have been associated with reductions in access to healthcare. We examined the effects of the introduction and removal of user fees on outpatient attendances and new diagnoses of HIV, malaria, and tuberculosis in Neno District, Malawi where user fees were re-instated at three of 13 health centres in 2013 and subsequently removed at one of these in 2015.MethodsWe conducted two analyses. Firstly, an unadjusted comparison of outpatient visits and new diagnoses over three periods between July 2012 and October 2015: during the period with no user fees, at the re-introduction of user fees at four centres, and after the removal of user fees at one centre. Secondly, we estimated a linear model of the effect of user fees on the outcome of interest that controlled for unobserved health centre effects, monthly effects, and a linear time trend.ResultsThe introduction of user fees was associated with a change in total attendances of −68 % [95 % CI: −89 %, −12 %], similar reductions were observed for new malaria and HIV diagnoses. The removal of user fees was associated with an increase in total attendances of 352 % [213 %, 554 %] with similar increases for malaria diagnoses. The results were not sensitive to control group or model specification.ConclusionsUser fees for outpatient healthcare services present a barrier to patients accessing healthcare and reduce detection of serious infectious diseases.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1856-x) contains supplementary material, which is available to authorized users.

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

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 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. 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. 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. 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. 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.

Impact of User Fees in Health Care System on Health Care Consumption

Impact of User Fees in Health Care System on Health Care Consumption In comparison to other European countries, it is claimed that the Czech Republic belongs to the countries with higher health care consumption, even if health status does not positively correlate with health care use. Therefore, user fees as a form of patient cost sharing were introduced to regulate health care consumption and to confront the patient with resource scarcity in the health care system as a part of health care reform package in 2008. The goal of the paper is to determine the changes in health care consumption after user fees implementation and evaluate their regulatory effect in a short period of time. The analysis of the changes in health care consumption is made on the basis of data from the largest health insurance company - VZP ČR (60 % of the Czech population). The health care consumption is monitored according to particular types of health care services for particular age groups in years 2007, 2008 and 2009. This analysis identifies the major changes in the consumption after user fees implementation among the observed age groups of Czech population. Furthermore, it is possible to prove the regulatory effect of user fees in a short period of time (2 years).

Rethinking Universal Access to Public Health-Care: User Fees do not Necessarily Constitute the Major Barrier

This paper is set to explain the relative importance of expanding geographical coverage of public health facilities to show that the impact of user fees on access to health-care might be over-emphasized, and thus undermine the impact due to perceptions and spatial distribution of health facilities. From a survey data of two rural districts in Tanzania, we tabulate the reasons why sick people did not consult for medical care. It is found that unlike user fees, travelling costs feature as the major reason for not consulting. We then make further analysis by expressing travelling costs as a proportion of the cost of medical care. It is found that accessing health services involves more than 50% of the costs of medical care. It is also observed that the poor have higher degree at which a health problem is perceived to be an illness that needs the attention of a medical doctor. Consequently, they consult lees often than the non-poor. We conclude that user fees are not necessarily the barrier to accessing health-care. Reduced travelling costs and time would potentially increase ability to pay fees. Therefore, travelling time and distance have to be reconsidered in policy design.

The impact of user fees on health service utilization in low- and middle-income countries: how strong is the evidence?

To assess the effects of user charges on the uptake of health services in low- and middle-income countries. 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. 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. 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.

Free care at the point of service delivery: a key component for reaching universal access to HIV/AIDS treatment in developing countries

User fees are a common feature of health system financing in low and middle-income countries. In the context of universal access to HIV/AIDS treatment and care, the advantages of user fees for funding at country and local level should be balanced with their clinical and public health impact. We reviewed the literature on user fees and the impact of user fees on HIV/AIDS service delivery. Empirical evidence gathered since the 1980s shows that sustainability, efficiency and equity challenges faced by health systems have persisted with and have often been exacerbated by the introduction of user fees. The evidence on HIV/AIDS suggests that free care at the point of service fosters uptake and helps to extend access for the poorest users. User fees are currently the main barrier to adherence to antiretroviral therapy (ART). Their abolition is associated with better virological results and increased survival. Such abolition should be carried out in parallel with the implementation of financing mechanisms, such as prepayment and risk pooling, which are able to gather funds from the sectors of the population who are able to pay for healthcare and to promote equity towards the poorest. WHO has included free access to HIV/AIDS treatment at the point of service delivery as a component of its public health approach for reaching universal access. Implementation of free HIV/AIDS care should, however, be linked to efforts to strengthen healthcare systems, ensure long-term sustainability of funding and monitor equity of access to care.

User fees and health service utilization in Vietnam: How to protect the poor?

Vietnam started its health reform process two decades ago, initiated by economic reform in 1986. Economic reform has rapidly changed the socio-economic environment with the transition from a centrally planned economy to a market-oriented economy. Health reform in Vietnam has been associated with the introduction of user fees, the legalization of private medical practices, and the commercialization of the pharmaceutical industry. This paper presents the user fees and health service utilization in Vietnam during a critical period of economic transition in the 1990s. The study is based on two national household surveys: the Vietnam Living Standard Survey 1992-1993 and 1997-1998. The concentration index and related concentration curve were used to measure differences in health service utilization as indicators of health outcomes of income quintiles, ranking from the poorest to the richest. User fees contribute to health resources and have helped to relieve the financial burden on the Government. However, comparisons of concentration indices for hospital stays and community health centre visits show that user fees can drive people deeper into poverty, widen the gap between the rich and the poor, and increase inequality in health outcomes. An effective social protection and targeting system is proposed to protect the poor from the impact of user fees, to increase equity and improve the quality of healthcare services. This cannot be done without taking measures to improve the quality of care and promote ethical standards in health care, including the elimination of unofficial payments.

Slutsky Decomposition Of Price Effects In Public Health Care

This paper employs the Slutsky decomposition of the effect of price change to identify impact of user fees on access to public health care. The paper starts with a theoretical outline that relates user fees to quality of health care before carrying out the Slutsky decomposition to identify the income and substitution effects of user fees in public health care. Delivery efficiency is observed as an important factor that shapes the impact of user fees on demand for the health care. The findings suggest that introduction of user fees in public health care without appropriate measures to boost quality of the services, may have negative effects on demand. Thus, delivery efficiency of public services matters as it fuels the effect of price change. African Journal of Finance and Management Vol.13(1) 2004: 17-24

Gender Dimensions of User Fees: Implications for Women’s Utilization of Health Care

This paper looks at the implications of user fees for women’s utilization of health care services, based on selected studies in Africa. Lack of access to resources and inequitable decision-making power mean that when poor women face out-of-pocket costs such as user fees when seeking health care, the cost of care may become out of reach. Even though many poor women may be exempt from fees, there is little incentive for providers to apply exemptions, as they too are constrained by restrictive economic and health service conditions. If user fees and other out-of-pocket costs are to be retained in resource-poor settings, there is a need to demonstrate how they can be successfully and equitably implemented. The lack of hard evidence on the impact of user fees on women’s health outcomes and reproductive health service utilization reminds us of the urgent need to examine how women cope with health care costs and what trade-offs they make in order to pay for health care. Such studies need to collect gender-disaggregated data in relation to women’s health service utilization and in relation to the range of reproductive health services, taking into account not only out-of-pocket fees charged by public health providers but also by private and traditional providers.

Regulatory Reform and Bureaucratic Responsiveness to Firms: The Impact of User Fees in the FDA

Regulatory Reform and Bureaucratic Responsiveness to Firms: The Impact of User Fees in the FDA

Regulatory Reform and Bureaucratic Responsiveness to Firms: the Impact of User Fees in the FDA

This paper examines the impact of user fees on the speed of new-drug review and on the responsiveness of FDA reviewers to pharmaceutical firms. User fees are expected to alter FDA behavior and responsiveness to pharmaceutical firms because they give regulators a financial incentive to process more new-drug applications and because they convey information to regulators that may reduce type I error. The analysis examines the variation in FDA review times for new drugs approved between 1990 and 1995 as a function of differences that exist among firms and drugs. Specifically, it compares estimates of regulator responsiveness to several firm and drug characteristics before and after the introduction of user fees. The results show that user fees produced a significant change in FDA behavior. Regulators have become less responsive to the differences among firms since the introduction of user fees, which suggests that the reform has led to more equity in the new-drug review process. In addition, the FDA has expedited the review of new drugs, especially the most therapeutically novel drugs, which suggests that politicians have been fairly successful in designing a reform to realign regulatory incentives in the FDA.

User Fees and Family Policy: Attempting to Recover Costs for State‐Provided Child Support Enforcement Services

This study looks in depth at three family policy issues surrounding one state's attempt to recover costs for child support enforcement services provided to nonpublic assistance families. The issues are whether a cost recovery user fee should be assessed; to whom the fee should be assessed; and how to develop a fee structure to meet criteria established by the policy agents. The original study was mandated by the state legislature. Recommendations were made to the legislature to continue one small fee, discontinue another unpopular fee, and institute three new broad‐based fees that would allow for nearly full cost recovery. In an election year the legislature accepted the first two recommendations but chose not to pursue the three new fees. Implications for policy development are drawn, focusing on the impact of user fees on service recipients and the role of the public sector in providing services that are available in the private sector in an era of tighter budgets.

Impact of user fees on attendance at a referral centre for sexually transmitted diseases in Kenya

We investigated the impact of a short-lived policy of charging fees to patients attending public-sector outpatient health facilities in Kenya by collecting data on attendance at Nairobi's Special Treatment Clinic for sexually transmitted diseases (STDs) before (23 months), during (9 months), and after (15 months) the user-charge period. During the user-charge period, the seasonally adjusted total mean monthly attendance of men decreased significantly to 40% (95% Cl 36-45) of that before fees were levied. Attendance rose in the post-user-charge period, but reached only 64% (59-68) of the pre-user-charge level. For women, the adjusted total mean monthly attendance during the user-charge period was reduced significantly to 65% (55-77) of the pre-user-charge level. Mean monthly attendance by women rose in the post-user-charge period to 22% (9-37) above the pre-user-charge level. There was no evidence of an increase in attendance over the course of the user-charge period among either men or women. The introduction of user fees probably increased the number of untreated STDs in the population, with potentially serious long-term health implications. The user-fee experience in Kenya should be carefully evaluated before similar measures are introduced elsewhere.

User Fees and Equity Issues in Public Hunting Expenditures: The Case of Ring-Necked Pheasant in Oregon

Declining real budgets for wildlife agencies are focusing attention on the potential for user fees to supply specific services. While Hemingway's statement may suggest the intensity of interest by some participants, few would believe that such sentiments reflect average willingness to pay. Valuation studies are therefore useful to assess both the likelihood of success of a fee system as well as equity consequences of fee structures. With such information, policy makers can compare likely revenues from user fees with the cost of supplying specific wildlife enhancement programs (Matulich, Workman and Jubenville 1987). Valuation information also enables policy makers to more fully understand attendant welfare effects. While use of nonmarket valuation procedures in this context is limited, some studies have assessed the impact of user fees for specific public goods (e.g., Huszar and Seckler 1974). The overall purpose of this study is to investigate economic aspects of implementing user fees for a public, game enhancement program for ring-necked pheasants in Oregon. The analysis is based on a closedform contingent valuation survey of hunters during the 1986 western Oregon pheasant season. Econometric estimates of a logit model are then used to estimate (1) willingness to pay for the existing program; (2) participation rates, revenue, and willingness to pay for programs with varying user fees, including a simple Ramsey price system; and (3) the distribution of these variables among income classes.

User fees for health care in developing countries: A case study of Bangladesh

In designing country health care programs to achieve the goals of the Alma Alta declaration of ‘Health for All’, developing countries have been confronted with the problem of increased health care needs and decreased available resources. Health economists have proferred several possible solutions to this fiscal shortfall, including cost-recovery measures through the imposition of user fees for curative services at government health facilities. Health care providers have been noticeably absent from discussions of the many possible implications of these fees; consequently, resultant programs and policies may be economically sound but may fail to place a sufficient emphasis on features designed to maintain and improve the health of the population. In the present paper we examine the possible impact of user fees on the health of individuals residing in Bangladesh, one potential candidate country for user fees. We note evidence that the existing government health care system appears already to be providing care to two of the most medically vulnerable groups in Bangladesh, the poor and women, and provide evidence that such fees may seriously interfere with maintaining this patient profile. We discuss the significant public health role that curative care provides for the individuals, their families and the wider community. We suggest that additional questions should be asked by health care providers, anthropologists and economists prior to institution of user fees in the government system and that such measures should first be introduced in an experimental format with a rigorous and comprehensive impact evaluation.