Removal of User Fees Associated with Increases In Delivery at Facilities

Abstract

The removal of user fees in Kenya, Ghana and Senegal resulted in 3.1 additional facility-based deliveries per 100 live births, representing a 5% increase, according to an analysis of Demographic and Health Survey (DHS) data from an array of Sub-Saharan African countries. (1) The estimated increase was smaller than that reported in prior analyses of individual countries, in part because those studies, unlike the current one, did not account for the increases that likely would have occurred even if user fees had still been required. Rates of caesarean delivery did not change following elimination of user fees; neonatal mortality declined by 9%, although the decrease was not statistically significant. The new analysis used DHS data collected between 1997 and 2012 to examine whether levels of the three outcomes--delivery at a facility, caesarean delivery and neonatal mortality--changed when countries eliminated user fees for facility-based delivery services. Three countries in Sub-Saharan Africa eliminated some or all such fees during the study period and served as the intervention group: Ghana, which eliminated fees for deliveries at all public, private and faith-based facilities in 2003 (selected regions) and 2005 (elsewhere); Kenya, which removed fees for deliveries at public dispensaries and health centers, but not at hospitals, in 2007; and Senegal, which eliminated fees at public facilities in most of the country in 2005-2006. The comparison group consisted of a pool of seven countries (Cameroon, Congo, Ethiopia, Gabon, Mozambique, Nigeria and Tanzania) that did not change their delivery fee policies. Although three of these countries had existing policies that exempted women from paying fees for maternity care, these exemptions were not widely known and were rarely enforced. In addition, because changes in fee policies in Ghana and Senegal were implemented in stages, women who gave birth during the transition period before fees were eliminated in their region of residence were included in the comparison group. To assess the relationship between removal of user fees and the three outcomes, the researchers used difference-in-differences regressions, which examined whether outcomes changed to a greater extent in countries with policy changes than in those without. All analyses adjusted for women's characteristics (age, area of residence, education, wealth and whether the woman had given birth previously), area fixed effects (which take into account regional characteristics) and year fixed effects (to account for time trends). In addition, to ensure appropriate comparisons, the investigators adjusted the make-up of the comparison groups for each outcome so that trends in the outcome were similar in the intervention and comparison groups prior to the removal of policy fees. For example, the comparison group for caesarean delivery excluded Nigeria, where the rate of such deliveries declined at an unusually high rate in 1995-2003; after that exclusion, the six remaining comparison countries and the three intervention countries had statistically similar rates of change in caesarean delivery levels prior to the fee removals. They also examined change levels by year to see if patterns (e.g., lags in improvements) were consistent with implementation of a new policy. The difference-in-differences analysis of facility deliveries yielded an average marginal effect of 3.1, which can be interpreted as indicating that removal of fees was associated with an additional 3.1 deliveries per 100 births, after adjustment for covariates. …