User fees and health facility service readiness: a Bayesian analysis of data from six low- and middle-income countries

BACKGROUND: User fee removal may improve affordability, but its implications for facility readiness are unclear. Evidence is limited on whether fee charging is associated with specific readiness domains, especially those dependent on recurrent operating funds. METHODS: This study conducted a cross-sectional secondary analysis of Service Provision Assessment facility audits from Afghanistan, Bangladesh, Ethiopia, Malawi, Nepal, and Tanzania (2013-22). Country-specific Bayesian linear mixed models estimated associations between any client fee charging and the overall Service Readiness Index (0-10) and its five domains, adjusting for rural location, other revenue sources, and service volume, with facility-type-by-managing-authority random intercepts. RESULTS: Associations with overall readiness varied by country. The largest adjusted differences were observed in Nepal (0.56, 95% credible interval 0.43-0.69) and Malawi (0.38, 0.14-0.61), with smaller positive estimates in Bangladesh and Ethiopia, uncertainty in Afghanistan, and little evidence in Tanzania. Across settings, associations were concentrated in diagnostic capacity and essential medicines. Tanzania showed no overall association and lower infection prevention readiness among facilities charging client fees. CONCLUSIONS: Charging client fees was most consistently associated with diagnostic capacity and essential medicines in stock, domains reliant on recurrent procurement. Systems offering care without user fees should ensure sustainable replenishment and monitor stocks.