Does charging different user fees for primary and secondary care affect first-contacts with primary healthcare?
Policy-makers in many countries are increasingly considering charging people different fees for using primary and secondary care services (differential user charges). The aim of such 'differential fees' is to encourage use of primary health care in health systems with limited gate keeping. We carried out a systematic review to evaluate the impact of introducing differential user charges on service utilisation. We reviewed studies published 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...