Financial accessibility and user fee reforms for maternal healthcare in five sub-Saharan countries: a quasi-experimental analysis

Abstract

ObjectivesEvidence on whether removing fees benefits the poorest is patchy and weak. The aim of this paper is to measure the impact of user fee reforms on the probability of giving birth in an institution or undergoing a caesarean section (CS) in Ghana, Burkina Faso, Zambia, Cameroon and Nigeria for the poorest strata of the population.SettingWomen's experience of user fees in 5 African countries.Primary and secondary outcome measuresUsing quasi-experimental regression analysis we tested the impact of user fee reforms on facilities’ births and CS differentiated by wealth, education and residence in Burkina Faso and Ghana. Mapping of the literature followed by key informant interviews are used to verify details of reform implementation and to confirm and support our countries’ choice.ParticipantsWe analysed data from consecutive surveys in 5 countries: 2 case countries that experienced reforms (Ghana and Burkina Faso) by contrast with 3 that did not experience reforms (Zambia, Cameroon, Nigeria).ResultsUser fee reforms are associated with a significant percentage of the increase in access to facility births (27 percentage points) and to a much lesser extent to CS (0.7 percentage points). Poor (but not the poorest), and non-educated women, and those in rural areas benefitted the most from the reforms. User fees reforms have had a higher impact in Burkina Faso compared with Ghana.ConclusionsFindings show a clear positive impact on access when user fees are removed, but limited evidence for improved availability of CS for those most in need. More women from rural areas and from lower socioeconomic backgrounds give birth in health facilities after fee reform. Speed and quality of implementation might be the key reason behind the differences between the 2 case countries. This calls for more research into the impact of reforms on quality of care.

Getting There: Overcoming Barriers to Reproductive and Maternal Health Services Access in Northern Togo-A Qualitative Study

“…One recommendation to address this challenge is to abolish fees or standardize small user fees and avoid additional unanticipated costs by providing health centers with a package of essential supplies to be provided to delivering women free of cost or at minimal charge. The impact of user fee removal on maternal health utilization is well documented, in particular for deliveries in health facilities, with a prerequisite of the availability of quality services and relevant essential medicines (Leone, Cetorelli, Neal, & Matthews, ).…”

Female Genital Mutilation/Cutting in Mali and Mauritania: Understanding Trends and Evaluating Policies

“…2014; Leone et al. 2016). Our approach is distinct from an analysis of repeated cross sections (e.g., using several consecutive DHS or MICS) because we create a continuous time series of rates of FGM/C.…”

“…2014; Leone et al. 2016). Our implementation of DID uses statistical analysis to calculate the effect of a policy (here, the 2005 Mauritanian law) on an outcome (FGM/C prevalence) by comparing the average change over time in prevalence in Mauritania to the average change over time in Mali.…”

“…Our analysis has four stages: (1) merging and preparing the data, (2) reconstructing trends in FGM/C prevalence by birth cohort, (3) using these trends to evaluate Mauritania's 2005 law, and (4) checking the reliability of findings by examining trends in FGM/C prevalence by year of FGM/C. We use an innovative research design that has not been applied previously to studies of FGM/C, but is broadly similar to an impact evaluation method that has been used to study other demographic and health outcomes, including adult mortality (Bendavid et al 2012), immunization coverage (Cetorelli 2015), and facility-based delivery (Bendavid et al 2012;McKinnon et al 2014;Leone et al 2016). Our approach is distinct from an analysis of repeated cross sections (e.g., using several consecutive DHS or MICS) because we create a continuous time series of rates of FGM/C.…”

“…We used a difference-in-difference (DID) method that allowed us to extract the maximum utility from existing data in order to better understand the impact of a national FGM/C law. This method is often used for policy evaluation, including evaluation of AIDS relief programs and user fees for health service removal (Bendavid et al 2012;McKinnon et al 2014;Leone et al 2016). Our implementation of DID uses statistical analysis to calculate the effect of a policy (here, the 2005 Mauritanian law) on an outcome (FGM/C prevalence) by comparing the average change over time in prevalence in Mauritania to the average change over time in Mali.…”