Transversal analysis of public policies on user fees exemptions in six West African countries

Abstract

BackgroundWhile more and more West African countries are implementing public user fees exemption policies, there is still little knowledge available on this topic. The long time required for scientific production, combined with the needs of decision-makers, led to the creation in 2010 of a project to support implementers in aggregating knowledge on their experiences. This article presents a transversal analysis of user fees exemption policies implemented in Benin, Burkina Faso, Mali, Niger, Togo and Senegal.MethodsThis was a multiple case study with several embedded levels of analysis. The cases were public user fees exemption policies selected by the participants because of their instructive value. The data used in the countries were taken from documentary analysis, interviews and questionnaires. The transversal analysis was based on a framework for studying five implementation components and five actors’ attitudes usually encountered in these policies.ResultsThe analysis of the implementation components revealed: a majority of State financing; maintenance of centrally organized financing; a multiplicity of reimbursement methods; reimbursement delays and/or stock shortages; almost no implementation guides; a lack of support measures; communication plans that were rarely carried out, funded or renewed; health workers who were given general information but not details; poorly informed populations; almost no evaluation systems; ineffective and poorly funded coordination systems; low levels of community involvement; and incomplete referral-evacuation systems. With regard to actors’ attitudes, the analysis revealed: objectives that were appreciated by everyone; dissatisfaction with the implementation; specific tensions between healthcare providers and patients; overall satisfaction among patients, but still some problems; the perception that while the financial barrier has been removed, other barriers persist; occasionally a reorganization of practices, service rationing due to lack of reimbursement, and some overcharging or shifting of resources.ConclusionsThis transversal analysis confirms the need to assign a great deal of importance to the implementation of user fees exemption policies once these decisions have been taken. It also highlights some practices that suggest avenues of future research.

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

“… 21 There is some evidence that the policy in Burkina Faso reduced out-of-pocket expenses and did not have an adverse effect on quality. 22 23 A further interesting point why uptake may have been greater in Burkina Faso was because the fee set for normal deliveries was significantly higher than the real cost. As highlighted in our interviews, the guidelines on how this money should be allocated were not clear, and in particular what proportion could be claimed by staff as bonuses.…”

How Burkina Faso used evidence in deciding to launch its policy of free healthcare for children under five and women in 2016

“…In Africa, "80 percent of countries (37 of the 41 countries that had use fees) have implemented reforms to reduce or eliminate user fees" (Cotlear and Rosemberg, 2018). However, several studies have shown that the decisions to introduce these user fees exemption policies in Africa were often electorally motivated, sudden, prompted by external pressures, and consequently very chaotic in their implementation (Meessen et al, 2011;Ridde, Queuille, et al, 2012;Olivier de Sardan and Ridde, 2015;Gautier and Ridde, 2017), even if their effects were often beneficial for populations. This was still the case at the end of 2017, such as in Gabon, where the President suddenly announced exemption from payment for deliveries without anything having been prepared on the ground.…”

Local initiatives to access emergency obstetric and neonatal care in Burkina Faso

“…These initiatives consisted of subsidizing medical interventions by 60%–80%. Consequently, women would pay 11 000 XOF (CFA Francs; US $18.3) for a cesarean delivery; while transfer of patients from a primary health center to a hospital became free [7–9].…”

“…Before and after implementation of this national initiative, other local initiatives (at district level) were developed to reduce the financial barriers for pregnant women and children under 5 years. Some of these initiatives have been documented in the literature [7–12].…”