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      A literature review of the disruptive effects of user fee exemption policies on health systems

      research-article
      1 , 2 , , 1 , 2 , 3
      BMC Public Health
      BioMed Central

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          Abstract

          Background

          Several low- and middle-income countries have exempted patients from user fees in certain categories of population or of services. These exemptions are very effective in lifting part of the financial barrier to access to services, but they have been organized within unstable health systems where there are sometimes numerous dysfunctions. The objective of this article is to bring to light the disruptions triggered by exemption policies in health systems of low- and middle-income countries.

          Methods

          Scoping review of 23 scientific articles. The data were synthesized according to the six essential functions of health systems.

          Results

          The disruptions included specifically: 1) immediate and significant increases in service utilization; 2) perceived heavier workloads for health workers, feelings of being exploited and overworked, and decline in morale; 3) lack of information about free services provided and their reimbursement; 4) unavailability of drugs and delays in the distribution of consumables; 5) unpredictable and insufficient funding, revenue losses for health centres, reimbursement delays; 6) the multiplicity of actors and the difficulty of identifying who is responsible (‘no blame’ game), and deficiencies in planning and communication.

          Conclusions

          These disruptive elements give us an idea of what is to be expected if exemption policies do not put in place all the required conditions in terms of preparation, planning and complementary measures. There is a lack of knowledge on the effects of exemptions on all the functions of health systems because so few studies have been carried out from this perspective.

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          Most cited references44

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          Scoping studies: towards a methodological framework

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            Systematic reviews: synthesis of best evidence for clinical decisions.

            Systematic reviews can help practitioners keep abreast of the medical literature by summarizing large bodies of evidence and helping to explain differences among studies on the same question. A systematic review involves the application of scientific strategies, in ways that limit bias, to the assembly, critical appraisal, and synthesis of all relevant studies that address a specific clinical question. A meta-analysis is a type of systematic review that uses statistical methods to combine and summarize the results of several primary studies. Because the review process itself (like any other type of research) is subject to bias, a useful review requires clear reporting of information obtained using rigorous methods. Used increasingly to inform medical decision making, plan future research agendas, and establish clinical policy, systematic reviews may strengthen the link between best research evidence and optimal health care.
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              Is Open Access

              Building the Field of Health Policy and Systems Research: Social Science Matters

              In the second in a series of articles addressing the current challenges and opportunities for the development of Health Policy and Systems Research (HPSR), Lucy Gilson and colleagues argue the importance of insights from the social sciences.
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                Author and article information

                Journal
                BMC Public Health
                BMC Public Health
                BMC Public Health
                BioMed Central
                1471-2458
                2012
                8 June 2012
                : 12
                : 289
                Affiliations
                [1 ]Department of Preventive and Social Medicine, Medical Faculty, University of Montréal, 3875, rue Saint-Urbain, Montréal, QC, Canada
                [2 ]Centre de recherche du Centre hospitalier de l’Université de Montréal, Montréal (CRCHUM), Montréal, Canada
                [3 ]Institute for Tropical Medicine, Antwerp, Belgium
                Article
                1471-2458-12-289
                10.1186/1471-2458-12-289
                3370991
                22521207
                96317165-da24-4fb1-819b-7cda08f7a638
                Copyright ©2012 Ridde et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Research Article

                Public health
                Public health

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