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Health Policy Plan. 2017 Jun 1;32(5):723-731. doi: 10.1093/heapol/czw178.

Does charging different user fees for primary and secondary care affect first-contacts with primary healthcare? A systematic review.

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Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London.
Saw Swee Hock School of Public Health, National University of Singapore.
Department of Primary Care and Public Health, School of Public Health, Imperial College London.
Health Economics Group, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London.


Policy-makers are increasingly considering charging users different fees between primary and secondary care (differential user charges) to encourage utilisation of primary health care in health systems with limited gate keeping. A systematic review was conducted to evaluate the impact of introducing differential user charges on service utilisation. We reviewed studies published in MEDLINE, EMBASE, the Cochrane library, EconLIT, HMIC, and WHO library databases from January 1990 until June 2015. We extracted data from the studies meeting defined eligibility criteria and assessed study quality using an established checklist. We synthesized evidence narratively. Eight studies from six countries met our eligibility criteria. The overall study quality was low, with diversity in populations, interventions, settings, and methods. Five studies examined the introduction of or increase in user charges for secondary care, with four showing decreased secondary care utilisation, and three showing increased primary care utilisation. One study identified an increase in primary care utilisation after primary care user charges were reduced. The introduction of a non-referral charge in secondary care was associated with lower primary care utilisation in one study. One study compared user charges across insurance plans, associating higher charges in secondary care with higher utilisation in both primary and secondary care. Overall, the impact of introducing differential user-charges on primary care utilisation remains uncertain. Further research is required to understand their impact as a demand side intervention, including implications for health system costs and on utilisation among low-income patients.


Primary healthcare; systematic review; user fees

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