User fee exemptions and equity in access to caesarean sections: an analysis of patient survey data in Mali

Abstract

IntroductionLittle rigorous evidence exists on how health service utilization varies across socioeconomic groups after a user fee exemption policy has been implemented, and the evidence that does exist is mixed. In this paper, we estimate the distribution of caesarean section deliveries across socioeconomic groups following Mali’s implementation of a fee exemption policy for caesareans in 2005.MethodsWe conducted a patient survey in 2010 to collect socioeconomic data from 2,477 women who had caesareans in a representative sample of 25 facilities across all regions of Mali. We used these data along with data from the most recent Demographic and Health Survey to construct a wealth index and classify women into population-based wealth groupings. We compared the wealth distribution of women delivering via caesarean section to that of a nationally representative sample of women giving birth.ResultsWe found that wealthier women make up a disproportionate share of those having free caesareans, five years after implementation of the fee exemption policy. Women in the richest two quintiles accounted for 58 percent of all caesareans, while women in the poorest two quintiles accounted for 27 percent of all caesareans. Fewer women in the poorest two-fifths of the population are receiving caesareans than what we would expect given their share in the population of women giving birth.ConclusionsWhile fee exemptions remove important financial barriers to accessing priority maternal health services, they are insufficient to ensure equal access among wealth groups.

The free delivery and caesarean policy in Morocco: how much do households still pay?

“…These wealth quintiles were created using the method reported by El‐Khoury et al . . We used the most recent data available from the DHS (2011) [1].…”

Understanding factors influencing home delivery in the context of user‐fee abolition in Northern Ghana: Evidence from 2014 DHS

“…Husbands often make decisions about family planning, child spacing, and family size. 32 The region has a number of health facilities, including one (1) teaching hospital, seven (7) polyclinics, ninety-four (94) health centers, forty-three (43) clinics, seven (7) maternity homes, and one hundred and eighty-one (181) functional CHPS compounds. 33 The region however regularly experiences shortage of health care workers and consumables, often culminating in poor health care delivery and reliance on herbal medical products and traditional birth attendants during childbirth.…”

“…The main argument in support of Ghana's user‐fee exemption policy is that financial costs are a major barrier to skilled care and that the poor would not be able to afford to pay for the use of necessary services . Indeed, within SSA, Senegal, Burkina Faso, Mali, Kenya, Niger, and Tanzania have implemented similar policies …”

“…4 Indeed, within SSA, Senegal, Burkina Faso, Mali, Kenya, Niger, and Tanzania have implemented similar policies. [5][6][7][8][9] Notwithstanding the popularity of this new health policy intervention, not all Ghanaian women deliver in health facilities. For example, national antenatal care (ANC) coverage of at least four visits increased from 92% in 2003 to 97% in 2014.…”

Trends in Institutional Caesarean Delivery among Low-Risk Patients in Senegal and Mali: Secondary Analysis of a Cluster-Randomized Trial (Quarite)

“…In sub-Saharan Africa (SSA), where population rates for caesareans are still very low, below the minimum threshold of 5% recommended by the World Health Organization (WHO) [2], there has been an increase in recent years [3,4]. In Mali and Senegal, free caesarean policies were implemented nationally since 2005 and have contributed to increase the access to caesarean sections [5,6]. In Senegal, caesarean rates have increased from 2.9% in 2005 to 4.7 in 2011 [3] and in Mali from 0.9% in 2005 to 2.3% in 2009 [7].…”