‘Rowing against the current’: the policy process and effects of removing user fees for caesarean sections in Benin

Dossou, Jean‐Paul; Cresswell, Jenny A.; Makoutode, Patrick; Brouwere, Vincent De; Witter, Sophie; Filippi, Véronique; Kanhonou, Lydie; Goufodji, Sourou; Lange, Isabelle; Lawin, Lionel; Affo, Fabien; Marchal, Bruno

doi:10.1136/bmjgh-2017-000537

Cited by 26 publications

(39 citation statements)

References 46 publications

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“…This lack of evidence results from both the number and quality of existing studies [23]. Despite this, there is consistency in the direction of effect, particularly when assessing the impact of fees on facility (primary health care-and hospital-level) deliveries [3][4][5][6][7][8][9][10][11][12]. Our findings are consistent with this trend and importantly are able to assess not only access to care but also delivery outcomes and the presentation of complications during delivery.…”

Section: Discussionsupporting

confidence: 57%

“…Maternal deaths can be greatly reduced by increasing the number of births attended by a skilled birth attendant, alongside timely access to secondary and tertiary care. There is a growing body of evidence to suggest removal or minimisation of fees for antenatal and delivery services improves maternal and neonatal outcomes and increases facilitybased deliveries [3][4][5][6][7][8][9][10][11][12]. Lesotho could improve its maternal mortalityamong the highest globallyby removing user fees for hospital delivery care.…”

Section: Global Contextmentioning

confidence: 99%

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Removal of user fees and system strengthening improves access to maternity care, reducing neonatal mortality in a district hospital in Lesotho

Steele

Sugianto

Baglione³

et al. 2018

Tropical Med Int Health

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Objective Lesotho has one of the highest maternal mortality rates in the world. While at primary health care (PHC) level maternity care is free, at hospital level co‐payments are required from patients. We describe service utilisation and delivery outcomes before and after removal of user fees and quality of delivery care, and associated costs, at St Joseph's Hospital (SJH) in Roma, Lesotho. Methods We compared utilisation of delivery services, stillbirths and maternal and neonatal mortality for the periods before (1 July 2012 to 31 December 2013) and after (1 January 2014 to 30 June 2015) user fee removal through a retrospective chart review and estimated additional costs attributed to user fee removal from provider (hospital) and patient perspectives. Results Of 4715 deliveries 3855 were at SJH and 860 at PHC centres. Of women delivering at SJH 684 (18.5%) were ≤19 years and 894 (23.6%) were HIV positive. After user fee removal hospital deliveries increased by 49% — from 1547 to 2308 — and neonatal mortality decreased from 4.8 to 1.3 per 1000 live births (P = 0.033). Extrapolating costs to the entire country, 1 USD per capita per year would allow user fee removal at hospital level, the provision of free transport to/from and accommodation at hospital. Conclusion Removing user fees for hospital delivery care in Lesotho is feasible and affordable, and has the potential to improve maternal and neonatal outcomes by removing financial barriers to skilled birth attendants and increasing coverage of institutional deliveries.

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Section: Discussionsupporting

confidence: 57%

Section: Global Contextmentioning

confidence: 99%

Removal of user fees and system strengthening improves access to maternity care, reducing neonatal mortality in a district hospital in Lesotho

Steele

Sugianto

Baglione³

et al. 2018

Tropical Med Int Health

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“…In Mali, a patient survey study conducted 5 years after implementation of the free C-section policy to estimate the distribution of C-sections across socioeconomic groups showed that wealthier women clearly had greater access to C-sections than poorer women [ 21 ]. Some studies showed that user fee removal was far from sufficient to ensure equity in access to maternal health care, and in some cases, it increased existing inequality in access [ 22 – 26 ].…”

Section: Introductionmentioning

confidence: 99%

Do free caesarean section policies increase inequalities in Benin and Mali?

Ravit

Audibert

Ridde

et al. 2018

Int J Equity Health

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BackgroundBenin and Mali introduced user fee exemption policies focused on caesarean sections (C-sections) in 2005 and 2009, respectively. These policies had a positive impact on access to C-sections and facility based deliveries among all women, but the impact on socioeconomic inequality is still highly uncertain. The objective of this study was to observe whether there was an increase or a decrease in urban/rural and socioeconomic inequalities in access to C-sections and facility based deliveries after the free C-section policy was introduced.MethodsWe used data from three consecutive Demographic and Health Surveys (DHS): 2001, 2006 and 2011–2012 in Benin and 2001, 2006 and 2012–13 in Mali. We evaluated trends in inequality in terms of two outcomes: C-sections and facility based deliveries. Adjusted odds ratios were used to estimate whether the distributions of C-sections and facility based deliveries favoured the least advantaged categories (rural, non-educated and poorest women) or the most advantaged categories (urban, educated and richest women). Concentration curves were used to observe the degree of wealth-related inequality in access to C-sections and facility based deliveries.ResultsWe analysed 47,302 childbirths (23,266 in Benin and 24,036 in Mali). In Benin, we found no significant difference in access to C-sections between urban and rural women or between educated and non-educated women. However, the richest women had greater access to C-sections than the poorest women. There was no significant change in these inequalities in terms of access to C-sections and facility based deliveries after introduction of the free C-section policy.In Mali, we found a reduction in education-related inequalities in access to C-sections after implementation of the policy (p-value = 0.043). Inequalities between urban and rural areas had already decreased prior to implementation of the policy, but wealth-related inequalities were still present.ConclusionsUrban/rural and socioeconomic inequalities in C-section access did not change substantially after the countries implemented free C-section policies. User fee exemption is not enough. We recommend switching to mechanisms that combine both a universal approach and targeted action for vulnerable populations to address this issue and ensure equal health care access for all individuals.

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“…Politics played vital role in the success and failures of some of the policymaking and policy implementation processes recorded in some of the West African countries. In Benin, Dossou et al [48] assessed user fees for caesarean sections and observed that policy development process suffered from inadequate uptake of evidence largely because the policy content and process were not completely in harmony with political goals. In Côte d'Ivoire, Blau et al [49] noted that a major success factor of the National Immunization Technical Advisory Group (NITAG) in promoting effective immunization policy was the strong political will from the government.…”

Section: Consider Political Acceptability Of the Policymentioning

confidence: 99%

Promoting the use of evidence in health policymaking in the ECOWAS region: the development and contextualization of an evidence-based policymaking guidance

Uneke

Sombié

Johnson

et al. 2020

Preprint

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Background The Economic Commission of the West African States (ECOWAS), through her specialised health Institution, the West African Health Organization (WAHO) is supporting Members States to improve health outcomes in West Africa. There is a global recognition that evidence-based health policies are vital towards achieving continued improvement in health outcomes. The need to have a tool that will provide systematic guide on the use of evidence in policymaking necessitated the production of the evidence-based policy-making (EBPM) Guidance. Methods Google search was performed to identify existing guidance on EBPM. Lessons were drawn from the review of identified guidance documents. Consultation, interaction and interviews were held with policymakers from the 15 West African countries during WAHO organized regional meetings in Senegal, Nigeria, and Burkina Faso. The purpose was to elicit their views on the strategies to promote the use of evidence in policymaking to be included in the EBPM Guidance. A regional Guidance Validation Meeting for West African policymakers was thereafter convened by WAHO to review findings from review of existing guidance documents and validate the EBPM Guidance. Results Out of the 250 publications screened, six publications fulfilled the study inclusion criteria and were reviewed. Among the important issues highlighted include: what evidence informed decision-making is; different types of research methods, designs and approaches, and how to judge the quality of research. The identified main target end users of the EBPM Guidance are policy/decision makers in the West African sub-region, at local, sub-national, national and regional levels. Among the key recommendations included in the EBPM Guidance include: properly defining/refining policy problem; reviewing contextual issues; initiating policy priority setting; considering political acceptability of policy; commissioning research; use of rapid response services, use of policy advisory/technical/steering committees; and use of policy briefs and policy dialogue. Conclusion The EBPM Guidance is one of the emerging tools that can enhance the understanding of evidence to policy process. The strategies to facilitate the use of evidence in policymaking outlined in the Guidance, can be adapted to local context, and incorporated validated approaches that can be used to promote evidence-to-policy-to-practice process in West Africa.

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‘Rowing against the current’: the policy process and effects of removing user fees for caesarean sections in Benin

Cited by 26 publications

References 46 publications

Removal of user fees and system strengthening improves access to maternity care, reducing neonatal mortality in a district hospital in Lesotho

Removal of user fees and system strengthening improves access to maternity care, reducing neonatal mortality in a district hospital in Lesotho

Do free caesarean section policies increase inequalities in Benin and Mali?

Promoting the use of evidence in health policymaking in the ECOWAS region: the development and contextualization of an evidence-based policymaking guidance

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