The Impact of Removing User Fees on Maternal and Child Health Services: A Systematic Review of Quasi-Experimental Studies

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DOI: 10.21522/TIJPH.2013.14.01.Art026

Authors : Peter Kofi Taadi, David Stuckler, Paul Abiodun Olaiya

Abstract:

User fee removal is emerging as a leading strategy to expand access to financial services for maternal and child health (MCH) services. However, whether such policies improve downstream outcomes or equity remains unclear. We conducted a systematic review of quasi-experimental studies evaluating the effects of user fee removal on the MCH continuum of care, mortality outcomes, and equity, guided by PRISMA and an original conceptual framework linking financial barriers to service use, quality, system readiness, and health outcomes. We searched PubMed and Web of Science in August 2025 for studies that used experimental or quasi-experimental designs evaluating user fee removal. Of the 933 records screened, 14 studies met the inclusion criteria; all were quasi-experimental. Narrative synthesis followed SWiM (Systematic Review Without Meta-analysis) guidelines due to heterogeneity, and risk of bias was assessed using ROBINS-I. Free health care policies consistently improved access to antenatal care, facility-based delivery, and skilled birth attendance. Effects on postnatal care and caesarean section were mixed. These improvements did not correspond to significant reductions in maternal mortality, stillbirths, or neonatal mortality. Removing user fees had no immediate effect on the initiation of early antenatal care but showed long-term gains. Some policies closed equity gaps while some unintentionally widened health disparities. Removing user fees significantly increased MCH utilisation, with limited or inconsistent effects on mortality and equity. Our framework clarifies how fee removal brings both benefits and system pressures. Future research should address quality and system readiness to achieve equitable outcomes.

References:

[1].   World Health Organization (WHO), & United Nations Children’s Fund (UNICEF), 1987, The Bamako Initiative. WHO/UNICEF. Accessed 10/12/2025. https://iris.who.int/server/api/core/bitstreams/93249aa1-5eac-409d-8f0d-c4fcc70fc5f3/content

[2].   World Bank, 1987, Financing Health Services in Developing Countries: An agenda for reform. Washington, DC: The World Bank. Accessed 10/12/2025. https://documents1.worldbank.org/curated/en/468091468137379607/pdf/multi-page.pdf

[3].   Lagarde, M., & Palmer, N., 2011, The impact of user fees on access to health services in low‐ and middle‐income countries. Cochrane Database of Systematic Reviews, 2011(4).

[4].   OkedoAlex, I. N., Akamike, I. C., Ezeanosike, O., & Uneke, C. J., 2019, Determinants of antenatal care utilisation in sub-Saharan Africa: A systematic review. BMJ Open.

[5].   Banke-Thomas, A., Ayomoh, F. I., Abejirinde, I. O., Banke-Thomas, O., Eboreime, E., & Ameh, C., 2020, Cost of utilizing maternal health services in low- and middle-income countries: A systematic review. International Journal of Health Policy and Management, 9(9), 409–420.

[6].   Sardan, J. O. D., & Ridde, V., 2015, Diagnosis of a public policy: An introduction to user fee exemptions for healthcare in the Sahel. BMC Health Services Research.

[7].   Dzakpasu, S., Powell-Jackson, T., & Campbell, O. M., 2014, Impact of user fees on maternal health service utilization and related health outcomes: A systematic review. Health Policy and Planning, 29(2), 137–150.

[8].   Andersen, R. M., 1995, Revisiting the behavioral model and access to medical care: Does it matter? Journal of Health and Social Behavior, 36(1), 1–10.

[9].   Donabedian, A., 1988, The quality of care—How can it be assessed? JAMA, 260(12), 1743–1748.

[10].  World Health Organization, 2010. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. Geneva, Switzerland: WHO.

[11].  Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T., Mulrow, C. D., ... & Moher, D., 2020, Mapping of reporting guidance for systematic reviews and meta-analyses generated a comprehensive item bank for future reporting guidelines. Journal of Clinical Epidemiology, 118, 60–68.

[12].  Qin, V. M., Hone, T., Millett, C., Moreno-Serra, R., McPake, B., Atun, R., & Lee, J. T., 2019, The impact of user charges on health outcomes in low-income and middle-income countries: A systematic review. BMJ Global Health, 3(Suppl 3), e001087.

[13].  Lagarde, M., & Palmer, N., 2008, The impact of user fees on health service utilization in low- and middle-income countries: How strong is the evidence? Bulletin of the World Health Organization, 86(11), 839–848.

[14].  Korachais, C., Macouillard, E., & Meessen, B., 2016, How user fees influence contraception in low- and middle-income countries: A systematic review. Studies in Family Planning, 47(4), 341–356.

[15].  Alfirevic, Z., Keeney, E., Dowswell, T., Welton, N. J., Medley, N., Dias, S., ... & Caldwell, D. M., 2016, Which method is best for the induction of labour? A systematic review, network meta-analysis and cost-effectiveness analysis. Health Technology Assessment, 20(65).

[16].  Ferede Gebremedhin, A., Dawson, A., & Hayen, A., 2022, Evaluations of effective coverage of maternal and child health services: A systematic review. Health Policy and Planning, 37(7), 895–914.

[17].  Tanahashi, T., 1978, Health service coverage and its evaluation. Bulletin of the World Health Organization, 56(2), 295–303.

[18].  Thaddeus, S., & Maine, D., 1994, Too far to walk: Maternal mortality in context. Social Science & Medicine, 38(8), 1091–1110.

[19].  Sheff, M. C., et al., 2020, Evaluating health service coverage in Ghana’s Volta Region using a modified Tanahashi model. Global Health Action, 13(1), 1732664.

[20].  Sterne, J. A., Hernán, M. A., Reeves, B. C., Savović, J., Berkman, N. D., Viswanathan, M., ... & Higgins, J. P., 2016, ROBINS-I: A tool for assessing risk of bias in non-randomised studies of interventions. BMJ, 355.

[21].  Bigool, M., 2024, Effects of free maternal healthcare on stunting in children under five years of age: Evidence from Ghana. Development Policy Review, 42(4).

[22].  Manthalu, G., Yi, D., Farrar, S., & Nkhoma, D., 2016, The effect of user fee exemption on the utilization of maternal health care at mission health facilities in Malawi. Health Policy and Planning, 31(9), 1184–1192.

[23].  Lang’at, E., Mwanri, L., & Temmerman, M., 2019, Effects of implementing free maternity service policy in Kenya: An interrupted time series analysis. BMC Health Services Research, 19(1), 645.

[24].  Orangi, S., Kairu, A., Malla, L., Ondera, J., Mbuthia, B., Ravishankar, N., & Barasa, E., 2021, Impact of free maternity policies in Kenya: An interrupted time-series analysis. BMJ Global Health, 6(6).

[25].  Owuor, H., & Amolo, A., 2019, Interrupted time series analysis of free maternity services policy in Nyamira County, Western Kenya. PLOS ONE, 14(5).

[26].  Demissie, A., Worku, A., & Berhane, Y., 2020, Effect of implementing a free delivery service policy on women’s utilization of facility-based delivery in Central Ethiopia: An interrupted time series analysis. Journal of Pregnancy, 2020.

[27].  Lagarde, M., Lépine, A., & Chansa, C., 2022, The long-term effects of free care on birth outcomes: Evidence from a national policy reform in Zambia. SSM - Population Health, 17, 101051.

[28].  Aye, T. T., Nguyen, H. T., Petitfour, L., Ridde, V., Amberg, F., Bonnet, E., Seynou, M., Kiendrébéogo, J. A., & De Allegri, M., 2024, How do free healthcare policies impact utilization of maternal and child health services in fragile settings? Evidence from a controlled interrupted time series analysis in Burkina Faso. Health Policy and Planning, 39(9), 891–901.

[29].  Oyugi, B., Nizalova, O., Kendall, S., & Peckham, S., 2024, Does a free maternity policy in Kenya work? Impact and cost-benefit consideration based on demographic health survey data. European Journal of Health Economics, 25(1), 77–89.

[30].  Renard, Y., 2022, From fees to free: User fee removal, maternal health care utilization and child health in Zambia. World Development, 156.

[31].  Gitobu, C., Gichangi, P., & Mwanda, W., 2018, The effect of Kenya’s free maternal health care policy on the utilization of health facility delivery services and maternal and neonatal mortality in public health facilities. BMC Pregnancy and Childbirth, 18.

[32].  McKinnon, B., Harper, S., & Kaufman, J. S., 2015, Who benefits from removing user fees for facility-based delivery services? Evidence on socioeconomic differences from Ghana, Senegal and Sierra Leone. Social Science & Medicine, 135, 117–123.

[33].  Hatt, L. E., Makinen, M., Madhavan, S., & Conlon, C. M., 2013, Effects of user fee exemptions on the provision and use of maternal health services: A review of literature. Journal of Health, Population, and Nutrition, 31(4 Suppl 2), S67.

[34].  Tesfaye, G., Loxton, D., Chojenta, C., Semahegn, A., & Smith, R. G., 2017, Delayed initiation of antenatal care and associated factors in Ethiopia: A systematic review and meta-analysis. Reproductive Health.

[35].  Jinga, N., Mongwenyana, C., Moolla, A., Malete, G., & Onoya, D., 2019, Reasons for late presentation for antenatal care, healthcare providers perspective. BMC Health Services Research.

[36].  Bhutada, K., Venkateswaran, M., Atim, M., Munabi-Babigumira, S., Nankabirwa, V., Namagembe, F., Fren, J., & Papadopoulou, E., 2024, Factors influencing the uptake of antenatal care in Uganda: A mixed methods systematic review. BMC Pregnancy and Childbirth, 24, 6938–6.

[37].  Ali, K., Abm, A. C., & Aimakhu, C., 2023, The utilization of antenatal care services among pregnant women in Somalia: A scoping review. The Open Public Health Journal, 16, 230322–2022–116.

[38].  Osei, K., Awog-badek, A. A., Prasiska, D., Chapagain, D. D., & Ha, M., 2025, Impact of Ghana’s fee exemption policy on maternal health service utilisation: An inverse probability of treatment weighting analysis of pooled national data. Journal of Global Health.

[39].  Garchitorena, A., Miller, A. C., Cordier, L. F., Rabeza, V. R., Randriamanambintsoa, M., Razanadrakato, H. T. R., ... & Bonds, M. H., 2018. Early changes in intervention coverage and mortality rates following the implementation of an integrated health system intervention in Madagascar. BMJ global health, 3(3).

[40].  Adepoju, V. A., Abdulrahim, A., & Adnani, Q. E. S., 2025, A systematic review of government-led free caesarean section policies in low- and middle-income countries from 2009 to 2025. Healthcare, 13(19), 2522.

[41].  Bou-Karroum, L., Iaia, D., El-Jardali, F., Samra, C. A., Salameh, S., Sleem, Z., Masri, R., Harb, A., Hemadi, N., Hilal, N., Hneiny, L., Nassour, S., Shah, M., & Langlois, E., 2024, Financing for equity for women’s, children’s and adolescents’ health in low- and middle-income countries: A scoping review. PLOS Global Public Health.