No effect of user fee exemption on perceived quality of delivery care in Burkina Faso: a case-control study

Aline Philibert,Aristide Bado,Valéry Ridde,Pierre Fournier

doi:10.1186/1472-6963-14-120

Abstract

BackgroundAlthough many developing countries have developed user fee exemption policies to move towards universal health coverage as a priority, very few studies have attempted to measure the quality of care. The present paper aims at assessing whether women’s satisfaction with delivery care is maintained with a total fee exemption in Burkina Faso.MethodsA quasi-experimental design with both intervention and control groups was carried out. Six health centres were selected in rural health districts with limited resources. In the intervention group, delivery care is free of charge at health centres while in the control district women have to pay 900 West African CFA francs (U$2). A total of 870 women who delivered at the health centre were interviewed at home after their visit over a 60-day range. A series of principal component analyses (PCA) were carried out to identify the dimension of patients’ satisfaction.ResultsWomen’s satisfaction loaded satisfactorily on a three-dimension principal component analysis (PCA): 1-provider-patient interaction; 2-nursing care services; 3-environment. Women in both the intervention and control groups were satisfied or very satisfied in 90% of cases (in 31 of 34 items). For each dimension, average satisfaction was similar between the two groups, even after controlling for socio-demographic factors (p = 0.436, p = 0.506, p = 0.310, respectively). The effects of total fee exemption on satisfaction were similar for any women without reinforcing inequalities between very poor and wealthy women (p ≥ 0.05). Although the wealthiest women were more dissatisfied with the delivery environment (p = 0.017), the poorest were more highly satisfied with nursing care services (p = 0.009).ConclusionContrary to our expectations, total fee exemption at the point of service did not seem to have a negative impact on quality of care, and women’s perceptions remained very positive. This paper shows that the policy of completely abolishing user fees with organized implementation is certainly a way for developing countries to engage in universal coverage while maintaining the quality of care.

Highlights

Many developing countries have developed user fee exemption policies to move towards universal health coverage as a priority, very few studies have attempted to measure the quality of care
Decreased quality in delivery care services may be the result of increased workload or declining staff morale, when the implementation of the exemption policy is not accompanied by a commensurate increase in human, material and financial resources [16]
Since 2006, Burkina Faso has implemented a national subsidy policy that covers 80% of fees for skilled deliveries in primary health care centres (Health and Social Promotion Centres, or CSPS), but the remainder must still be paid by the women [23]

Summary

Introduction

Many developing countries have developed user fee exemption policies to move towards universal health coverage as a priority, very few studies have attempted to measure the quality of care. Decreased quality in delivery care services may be the result of increased workload or declining staff morale, when the implementation of the exemption policy is not accompanied by a commensurate increase in human, material and financial resources [16]. This type of decline in care service quality may cause frustration among patients [17], especially the poorest women, who usually suffer poor treatment, as health workers are likely to give preference to wealthy women who offer tips and bribes [18]. The present study attempts to gather evidence on satisfaction with quality of care of skilled delivery for women who benefited from total fee exemption and those who did not (still paying 20% of fees)

Methods

Results

Discussion

Conclusion