title: A literature review of the disruptive effects of user fee exemption policies on health systems.
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.
authors.affiliation: Department of Preventive and Social Medicine, Medical Faculty, University of Montréal, 3875, rue Saint-Urbain, Montréal, QC, Canada. valery.ridde@umontreal.ca
authors.forename: Valéry
authors.initials: V
authors.lastname: Ridde
authors.forename: Emilie
authors.initials: E
authors.lastname: Robert
authors.forename: Bruno
authors.initials: B
authors.lastname: Meessen
mesh_terms: D003695:Delivery of Health Care; D003906:Developing Countries; D005249:Fees and Charges; D006291:Health Policy; D006297:Health Services Accessibility / Q000191:economics*; D006801:Humans