Removing user fees for facility-based delivery services: a difference-in-differences evaluation from ten sub-Saharan African countries

McKinnon, Britt; Harper, Sam; Kaufman, Jay S.; Bergevin, Yves

doi:10.1093/heapol/czu027

Cited by 122 publications

(136 citation statements)

References 33 publications

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“…This policy of free costs delivery is a response to a logic of social justice that seeks to avoid the poorer to be marginalized and to be in permanent exclusion. In most countries where these policies have been implemented, they favored access to health care for the poor [21] [22]…”

Section: Discussionmentioning

confidence: 99%

Study of the Factors Associated with Home Delivery in a Situation of Free Care in Senegal

Faye¹,

Tal-Dia²,

Faye³

2017

OJEpi

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Introduction: Home delivery is still a health problem in Kolda (Senegal). The aim of this work is to study the factors associated with the place of delivery in a situation of free care delivery. Method: A descriptive and analytical cross-sectional study was carried out. Sampling was in two-stage clusters. The study focused on women who gave birth in the last 12months. The data were collected during an individual interview at home. The collection focused on knowledge, attitudes and practices about delivery. Logistic regression was used to explore the determinants of childbirth at the level of health facility. Results: The average age was 25.4 ± 6.5 years. Among the interviewed women, education was reported in 35% of the women and 55% of women estimate that the closest health facility is within 5 km to their home. The time to get to the nearest health facility is less than 15 minutes for 39% of the interviewed women. The prevalence of home delivery was 43.5%. Home delivery was related to the remoteness of the health facility (2.43 [1.75 -3.37]) but also to incomplete antenatal care (2.52 [1.59 -4.00]). Support groups highlighted difficulties of access to health facilities because of remoteness. Interviews revealed a lack of involvement of husbands in seeking care for women. Cultural barriers are still there. Conclusions: Despite the gratuity of delivery, the remoteness of health structures and socio-cultural factors are still barriers to access to care for pregnant women. These aspects must be taken into account in health policies. Multi-lateral interventions should be implemented to provide solutions for this health problem.

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Section: Discussionmentioning

confidence: 99%

Study of the Factors Associated with Home Delivery in a Situation of Free Care in Senegal

Faye¹,

Tal-Dia²,

Faye³

2017

OJEpi

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“…It is possible that the policy, despite being announced, was not completely internalized by either the health districts or expectant mothers. In other words, the data that is available could be too early to detect effects on deliveries in public facilities, and, therefore, it is recommended that this research be extended to include future ZDHS waves [13]. …”

Section: Discussionmentioning

confidence: 99%

“…To reduce MMR through reductions in home deliveries, many sub-Saharan African countries abolished or reduced health service user fees [7–9], or exempted groups from payment requirements [10, 11]. The expected effect, an inverse relationship between delivery service user fees and delivery service utilisation as implied by the economic law of demand [10–13], has been uncovered, although not uniformly [7]. Two systematic reviews of user fee abolition argue that there is a dearth of robust evidence supporting the hypothesis that user fee reductions raise utilisation [14, 15].…”

Section: Introductionmentioning

confidence: 99%

An assessment of the effect of user fee policy reform on facility-based deliveries in rural Zambia

Chama-Chiliba

Koch

2016

BMC Res Notes

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BackgroundImproving maternal health outcomes by reducing barriers to accessing maternal health services is a key goal for most developing countries. This paper analyses the effect of user fee removal, which was announced for rural areas of Zambia in April 2006, on the use of public health facilities for childbirth.MethodsData from the 2007 Zambia Demographic and Health Survey, including birth histories for the five years preceding the survey, is linked to administrative data and geo-referenced health facility census data. We exploit a difference-in-differences design, due to a differential change in user fees at the district level; fees were removed in 54 rural districts, but not in the 18 remaining urban districts. We use multilevel modelling to estimate the effect of this policy change, based on 4018 births from May 2002 to September 2007, covering a period before and after the policy announcement in April 2006.ResultsThe difference-in-difference estimates point to statistically insignificant changes in the proportion of women giving birth at home and in public facilities, but significant changes are found for deliveries in private (faith-based) facilities. Thus, the abolition of delivery fees is found to have some effect on where Zambian mothers choose to have their children born.ConclusionThe removal of user fees has not overcome barriers to the utilisation of delivery services at public facilities. User fee removal may also yield unintended consequences deterring the utilisation of delivery services. Therefore, abolishing user fees, alone, may not be sufficient to affect changes in utilisation; instead, other efforts, such as improving service quality, may have a greater impact.

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“…Quasi-experimental designs, such as difference-in-differences (DD), can account for secular trends in the outcome by using a control group to estimate the counterfactual outcome trajectories (i.e., the outcome trend in the post-policy period had the policy change not occurred). We recently used a DD design to evaluate the effects of user fee exemption policies, finding evidence that removing fees increased facility-based deliveries and possibly contributed to a reduction in neonatal mortality (McKinnon et al, 2015). In this paper, we extend our previous work to investigate whether there are differential effects of the fee exemption policy across socioeconomic groups.…”

Section: Introductionmentioning

confidence: 87%

Who benefits from removing user fees for facility-based delivery services? Evidence on socioeconomic differences from Ghana, Senegal and Sierra Leone

McKinnon

Harper

Kaufman

2015

Social Science & Medicine

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Coverage of skilled delivery care has been increasing across most low-income countries; however, it remains far from universal and is very unequally distributed according to socioeconomic position. In an effort to increase coverage of skilled delivery care and reduce socioeconomic inequalities, governments of several countries in sub-Saharan Africa have recently adopted policies that remove user fees for facility-based delivery services. There is little rigorous evidence of the impact of these policies and few studies have examined effects on socioeconomic inequalities. This study investigates the impact of recent delivery fee exemption policies in Ghana, Senegal, and Sierra Leone on socioeconomic differences in the use of facility-based delivery services. Using Demographic and Health Survey data from nine sub-Saharan African countries, we evaluated the user fee policy changes using a difference-in-differences approach that accounts for underlying common secular trends and time invariant differences among countries, and allows for differential effects of the policy by socioeconomic position. Removing user fees was consistent with meaningful increases in facility deliveries across all categories of household wealth and maternal education. We found little evidence of differential effects of removing user fees across quartiles of household wealth, with increases of 5.4 facility deliveries per hundred live births (95% CI: 2.1, 8.8) among women in the poorest quartile and 6.8 per hundred live births (95% CI: 4.0, 9.7) for women in the richest quartile. However, our results suggest that educated women benefited more from removing user fees compared to women with no education. For women with at least some secondary education, the estimated effect was 8.6 facility deliveries per hundred live births (95% CI: 5.4, 11.9), but only 4.6 per hundred live births (95% CI: 2.2, 7.0) for women with no education (heterogeneity p-value = 0.04). Thus, while removing fees at the point of service increased facility deliveries across the socioeconomic gradient, it did not reduce inequalities defined by household wealth and may have contributed to a widening of educational inequalities. These findings emphasize the need for concerted efforts to address financial and other barriers that contribute to large and persistent socioeconomic inequalities in delivery care.

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Removing user fees for facility-based delivery services: a difference-in-differences evaluation from ten sub-Saharan African countries

Abstract: Our findings suggest removing user fees increased facility-based deliveries and possibly contributed to a reduction in NMR. Evidence from this evaluation may be useful to governments weighing the potential benefits of removing user fees.

Cited by 122 publications

References 33 publications

Study of the Factors Associated with Home Delivery in a Situation of Free Care in Senegal

Study of the Factors Associated with Home Delivery in a Situation of Free Care in Senegal

An assessment of the effect of user fee policy reform on facility-based deliveries in rural Zambia

Who benefits from removing user fees for facility-based delivery services? Evidence on socioeconomic differences from Ghana, Senegal and Sierra Leone

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