The impact of health financing strategies on access to health services in low and middle income countries (Protocol)

Publication Details

Lagarde, M. and Palmer, N. The impact of health financing strategies on access to health services in low and middle income countries. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD006092. DOI: 10.1002/14651858.CD006092.

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Mylene Lagarde and Natasha Palmer
East Asia and Pacific (includes South East Asia), South Asia, Middle East and North Africa, Sub-Saharan Africa, Latin America and the Caribbean, Commonwealth of Independent States
Health Nutrition and Population
Health Financing, Insurance and User Fees
Equity Focus
None specified
Review Type
Effectiveness review


Generally the governments of developing countries have scarce resources to meet the huge demand for health-care financing, and usually they resort to a combination of alternatives, such as social and private insurance schemes, and funding by foreign donors, non-government organisations, communities and households.Studies have shown that during the 1980smost developing countries were experiencing budget deficits, which led to a decline in the quantity and quality of government-subsidised health services. This in turn increased dependence on user fees (patient payments), but negative effects of patient-payment systems, such as a limited focus on equity and accessibility, soon became apparent. To overcome these problems, various other health-financing mechanisms have been developed which aim to increase the accessibility of health-care services for the poor. Evidence of the impact of different health-financing mechanisms is synthesised in this review.

Research objectives

As stated by theauthors: ”This review aims to assess the effectiveness of a range of financial mechanisms in improving access to care in low- and middle-income countries, and (where possible) to assess the health outcomes.”


The authors will include randomised controlled trials, interrupted time series and controlled before-and-after studies undertaken in low- and middle-income countries.They will include studies assessing health-financing mechanism used to reduce the financial burdens incurred by individuals, focusing on the following four types of intervention: (1) user fees, (2) prepayment schemes such as voluntary insurance (private and community-based insurance and social health insurance), (3) vouchers/conditional cash transfers/fee exemptions, and (4) institution-based or provider-based schemes such as performance-based payments. The primary outcomes that will be measured are change in access to health care and health expenditure, which will be done principally by assessing changes in the utilisation of health services.

They will search the published and unpublished literature, including bibliographic databases such as PubMED, EMBASE (Athens), Popline and CAB-Direct (Global Health) will be searched, The Cochrane Central Register of Controlled Trials (CENTRAL), in addition to development-studies databases like ELDIS, BLDS and ID21. Economics databases (J-STOR, IDEAS, etc.) and French and Spanish/South American databases will also be searched. The search will also involve checking reference lists of all relevant reviews or papers identified, and contacting authors/experts. Data collection, extraction and quality assessment will be done by two reviewers. A structured qualitative approach will be used to analyse the results. A quantitative analysis for ITS studies will be conducted. Contextual factors affecting the generalisability of results will also be documented.

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