Hatt Laurel E, Makinen Marty, Madhavan Supriya, Conlon Claudia M
J Health Popul Nutr. 2013 Dec;31(4 Suppl 2):67-80.
User fee removal has been put forward as an approach to increasing priority health service utilization, reducing impoverishment, and ultimately reducing maternal and neonatal mortality. However, user fees are a source of facility revenue in many low-income countries, often used for purchasing drugs and supplies and paying incentives to health workers. This paper reviews evidence on the effects of user fee exemptions on maternal health service utilization, service provision, and outcomes, including both supply-side and demand-side effects. We reviewed 19 peer-reviewed research articles addressing user fee exemptions and maternal health services or outcomes published since 1990. Studies were identified through a USAID-commissioned call for evidence, key word search, and screening process. Teams of reviewers assigned criteria-based quality scores to each paper and prepared structured narrative reviews. The grade of the evidence was found to be relatively weak, mainly from short-term, non-controlled studies. The introduction of user fee exemptions appears to have resulted in increased rates of facility-based deliveries and caesarean sections in some contexts. Impacts on maternal and neonatal mortality have not been conclusively demonstrated; exemptions for delivery care may contribute to modest reductions in institutional maternal mortality but the evidence is very weak. User fee exemptions were found to have negative, neutral, or inconclusive effects on availability of inputs, provider motivation, and quality of services. The extent to which user fee revenue lost by facilities is replaced can directly affect service provision and may have unintended consequences for provider motivation. Few studies have looked at the equity effects of fee removal, despite clear evidence that fees disproportionately burden the poor. This review highlights potential and documented benefits (increased use of maternity services) as well as risks (decreased provider motivation and quality) of user fee exemption policies for maternal health services. Governments should link user fee exemption policies with the replacement of lost revenue for facilities as well as broader health system improvements, including facility upgrades, ensured supply of needed inputs, and improved human resources for health. Removing user fees may increase uptake but will not reduce mortality proportionally if the quality of facility-based care is poor. More rigorous evaluations of both demand- and supply-side effects of mature fee exemption programmes are needed.
取消用户收费已被提出作为一种增加优先卫生服务利用率、减少贫困并最终降低孕产妇和新生儿死亡率的方法。然而，在许多低收入国家，用户收费是医疗机构收入的一个来源，通常用于购买药品和物资以及向卫生工作者支付激励费用。本文综述了关于免除用户收费对孕产妇卫生服务利用、服务提供及结果影响的证据，包括供给侧和需求侧的影响。我们回顾了19篇自1990年以来发表的关于免除用户收费与孕产妇卫生服务或结果的同行评审研究文章。通过美国国际开发署委托征集证据、关键词搜索和筛选过程来确定研究。评审团队为每篇论文分配基于标准的质量评分，并编写结构化的叙述性综述。发现证据等级相对较弱，主要来自短期的、非对照研究。在某些情况下，免除用户收费似乎导致了机构分娩率和剖宫产率的上升。对孕产妇和新生儿死亡率的影响尚未得到确凿证明；分娩护理的豁免可能有助于适度降低机构孕产妇死亡率，但证据非常薄弱。发现免除用户收费对投入品的可获得性、提供者的积极性和服务质量有负面、中性或不确定的影响。医疗机构损失的用户收费收入被替代的程度会直接影响服务提供，并且可能对提供者的积极性产生意想不到的后果。尽管有明确证据表明收费给穷人带来了不成比例的负担，但很少有研究考察取消收费的公平影响。本综述强调了孕产妇卫生服务免除用户收费政策的潜在和已记录的益处（增加产科服务的使用）以及风险（提供者积极性和质量下降）。政府应将免除用户收费政策与弥补医疗机构损失的收入以及更广泛的卫生系统改善联系起来，包括设施升级、确保所需投入品的供应以及改善卫生人力资源。如果机构护理质量差，取消用户收费可能会增加使用率，但不会成比例地降低死亡率。需要对成熟的免除收费计划的需求侧和供给侧影响进行更严格的评估。
