Monday, April 18, 2011

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

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


Mylene Lagarde1, Natasha Palmer1
1Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
Cochrane Database of Systematic Reviews 2011, Issue 4. Art. No.: CD009094. DOI: 10.1002/14651858.CD009094.


The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. April 2011


Available online at: http://bit.ly/i9BXLA

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.

 

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This message from the Pan American Health Organization, PAHO/WHO, is part of an effort to disseminate
information Related to: Equity; Health inequality; Socioeconomic inequality in health; Socioeconomic
health differentials; Gender; Violence; Poverty; Health Economics; Health Legislation; Ethnicity; Ethics;
Information Technology - Virtual libraries; Research & Science issues.  [DD/ KMC Area]
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"Materials provided in this electronic list are provided "as is". Unless expressly stated otherwise, the findings
and interpretations included in the Materials are those of the authors and not necessarily of The Pan American
Health Organization PAHO/WHO or its country members".
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[EQ] Integrating Social Determinants of Health and Health Equity into Canadian Public Health Practice

Integrating Social Determinants of Health and Health Equity into Canadian Public Health Practice:

Environmental Scan 2010

National Collaborating Centre for Determinants of Health (NCCDH)

St. Francis Xavier University – March 2011

Available online PDF [90p.] at: http://bit.ly/gboXhJ

“…..environmental scan to inform its future direction, priorities and activities through an analysis of the key challenges, needs, gaps, and opportunities in the determinants of health for public health.


A four-member expert reference group was established to provide strategic input into the conduct of the scan.


This environmental scan utilized four information gathering approaches:
- a focussed scan of the literature;
- 31 key informant interviews with practice and research experts;
- four focus group teleconferences to validate early emerging themes; and,  
- an online survey with over 600 respondents.
There was considerable convergence of the findings across the four information gathering approaches.


Despite public health’s more distant and recent history, public health action on broader health determinants is not widespread and may even be viewed as ‘new’. Either the application of foundational concepts was never universally institutionalized throughout public health or enough time has passed and pressures exerted upon the public health sector that they have been lost. Even within early adopter organizations, action on determinants of health is still at a relatively early stage of implementation versus having been institutionalized throughout. …”

“…..A number of pervasive challenges are barriers to more widespread action. These include: the lack of clarity regarding what public health should or could do; a limited evidence base; preoccupation with behaviour and lifestyle approaches; bureaucratic organizational characteristics; limitations in organizational capacity; the need for leadership; more effective communication; and supportive political environments.

 

Overall, there appear to be four key roles for public health action on health determinants to reduce health inequities:

·         Assess and report on the health of populations describing the existence and impact of health inequalities and inequities and, effective strategies to address those inequalities/inequities.

·         Modify/orient public health interventions to reduce inequities including the consideration of the unique needs and capacities of priority populations (i.e., do planning and implementation of existing programs considering inequities).

·         Engage in community and multi-sectoral collaboration in addressing the health needs of these populations through services and programs (i.e., when looking at the collectivity of our programming for ‘x’, where are the gaps?).

·         Lead/participate and support other stakeholders in policy analysis, development and advocacy for improvements in health determinant/inequities…”

 

Content:

Executive Summary

1. Introduction .

2. Methodology

3. Findings

Context for Public Health Action on the Determinants of Health

Key Concepts and Terminology

Public Health’s Roots and History .

Recent Major Reports Addressing Health Determinants and Equity – Selected Examples .

Formal Expectations for Public Health Action on Health Determinants and Health Inequalities/Inequities .

State of Public Health Action on Determinants of Health and Health Inequities

Challenges to Public Health Action

Opportunities (Reasons for Optimism)

4. Analysis and Implications for Future NCCDH Actions

5. Conclusion and Next Steps

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 *      *     *
This message from the Pan American Health Organization, PAHO/WHO, is part of an effort to disseminate
information Related to: Equity; Health inequality; Socioeconomic inequality in health; Socioeconomic
health differentials; Gender; Violence; Poverty; Health Economics; Health Legislation; Ethnicity; Ethics;
Information Technology - Virtual libraries; Research & Science issues.  [DD/ KMC Area]
Washington DC USA

“Materials provided in this electronic list are provided "as is". Unless expressly stated otherwise, the findings
and interpretations included in the Materials are those of the authors and not necessarily of The Pan American
Health Organization PAHO/WHO or its country members”.
------------------------------------------------------------------------------------
PAHO/WHO Website
Equity List - Archives - Join/remove: http://listserv.paho.org/Archives/equidad.html
Twitter http://twitter.com/eqpaho





IMPORTANT: This transmission is for use by the intended
recipient and it may contain privileged, proprietary or
confidential information. If you are not the intended
recipient or a person responsible for delivering this
transmission to the intended recipient, you may not
disclose, copy or distribute this transmission or take
any action in reliance on it. If you received this transmission
in error, please dispose of and delete this transmission.

Thank you.