From fees to free: impacts of user fee removal on child health outcomes - a systematic review.

backgroundUser fees are a major barrier to accessing healthcare for children, especially in low- and middle-income countries. Policymakers have adopted free care policies to improve utilization and health outcomes, yet evidence specific to children remains fragmented. This systematic review synthesizes the impact of removing user fees on child health.

methodsFollowing PRISMA guidelines, we searched PubMed, Scopus, and Web of Science for English-language studies published between January 1, 2010, and July 31, 2025. Studies were eligible if they assessed complete user fee removal for children (< 18 years), used experimental or quasi-experimental designs with control or pre–post comparisons, and reported at least one objective outcome on healthcare utilization, costs, or health status. Quality was appraised using the Joanna Briggs Institute checklist. Due to heterogeneity, findings were narratively synthesized by outcome category.

resultsOf 6,733 records identified, 38 studies from 16 countries were included, mostly from low-income African settings and targeting children under six. Most policies covered free outpatient primary care. Utilization increased in nearly all studies assessing outpatient visits (26/27) and in most inpatient service assessments. General health improvements included reduced anemia, fewer illness days, and better nutritional indicators. Child mortality declined in most studies, with reductions up to 92% for malaria-specific deaths. Financial protection improved in 12 studies, often with > 50% reductions in out-of-pocket payments. Equity effects were mixed, though several studies reported narrowing income-related gaps.

conclusionsRemoving user fees for children is generally associated with improvements in access, health outcomes, and financial protection and, in some contexts, greater equity. However, the magnitude and sustainability of these benefits depend on health system readiness, predictable financing, and efforts to address non-financial barriers such as transportation and service quality. Without parallel investments in infrastructure, workforce, and supply chains, free care policies risk overburdening facilities and undermining quality. When integrated into broader universal health coverage strategies, user fee removal can be a powerful tool for improving child health and reducing inequalities.