The pro-poor benefit of user fee exemption
There is extensive literature on the impact of abolishing user fees on women’s use of health services. For instance, a recent study analysed the effectiveness of the exemption policy and the distribution of its benefits in Burkina Faso. By reducing household expenses, all categories of the population benefited from this policy, including the poorest. However, subsidizing medical costs did not reduce inequalities in the way pregnant women used healthcare. In fact, to improve service utilization by the poorest and reduce expenses more significantly for women living far from health centres, lowering healthcare costs is probably not enough. There are still other financial and geographic barriers to access that need to be removed to increase institutional care for the poorest .
There is a consensus that removing or reducing financial barriers increases the number of institutional births. However, fewer studies analyse the risk of further impoverishment in cases where fees have not been totally abolished or where women have to pay other out-of pocket costs at the point of use. Our study shows that total exemption of user fees, such as in Sebba, can be beneficial in reducing excessive expenses for women using delivery care. However, when the additional subsidy was not applied correctly, such as in Dori, household expenditure for direct delivery care costs did not change significantly compared to health centres with only partial exemption. In the Sebba district, where full exemption of user fees was applied, reduction of excessive health expenses was more significant in poor quintiles. It can be argued that, in case of total exemption, the positive impact on poor households would be significant and would contribute to greater equity between the poorest and the richest.
Similar to Ghana’s experience, the elimination of user fees in two of Burkina Faso’s districts benefitted pregnant women regardless of their socio-economic status. Ghana has introduced a similar exemption policy directed at making delivery care free. Findings showed that with its universal application, the policy of abolishing user fees also benefited the poor, thereby addressing the equity issue in their health system. In fact, 18 months after user fees were abolished the greatest increase in health facility use was by the poorest segment of the population .
This positive impact of the abolition of user fees on the health care seeking behaviour and on the out-of-pocket expenditures observed in Ghana should encourage Burkina Faso’s Government to expand the full exemption pilot project to the national level.
In a country where almost 46% of the population lives below the threshold of absolute poverty , it is important to implement poverty reduction strategies. Full user fee exemptions could improve access to institutional birthing facilities and reduce poverty by decreasing excessive medical expenses. In fact, we already observed that access to facility-based delivery improves dramatically with the reduction of user fees. In three years, institutional deliveries increased by 35 to 50 percentage point in Sebba and Dori and only by 14 percentage point in the control district (Djibo) (see Table 4). Scaling up the full user fee exemption to the national level would certainly broaden its impact.
Results in the three districts show inadequate implementation of the user-fee exemption, especially for Dori and Djibo. In fact, respectively 21% and 19% of the women are still paying for drugs and consumables, which should be covered under both the government’s and NGO’s exemptions program. During the household surveys, women reported that they were still paying for items that should be free, such as gloves, syringes and drugs. In addition, in Dori, women are still facing out-of-pocket expenses whereas all the births are supposed to be “free” to the user. When these results were shared in a workshop with different stakeholders in November 2010, health professionals from the region gave some explanations for the added expenses. The main one arising from the discussion was the lack of understanding and confusion regarding both exemption programs . In cases where the nurses and midwives were unclear about the procedures and products included in the subsidies, the patient would end up paying. A second explanation suggested by the staff for the cost of drugs and consumables charged to users was a shortage of products in the health centre pharmacy. In some remote health centres, the pharmacy management was seen as a major challenge, forcing the women to buy the required products for the non-complicated delivery from a private pharmacy. The hypothesis given by health workers about a shortage of products needs to be verified with more qualitative research. However, a similar study in another district (Ouargaye), demonstrated that supply shortages in health centre pharmacies were very rarely involved in the additional expenses incurred by the women. Occasionally, because of the absence of the community pharmacy manager, health workers send patients to a private pharmacy in the village. The study, conducted in a single district, confirmed, measured, and explained why the flat fee was not respected when the policy was implemented. Because this situation has been shown to exist in other districts of the country, it is reasonable to believe that it is a national problem.
The role of drug supply shortages was not really confirmed. However, the combination of three factors: i) products not included in the delivery kit, ii) lack of understanding of the exemption policy and iii) informal charges by health workers; explains part of the implementation gap of the policy at the local level. Nonetheless, more qualitative research is needed to understand all the plausible causes of this gap .
Information about the specific components of the exemption policy remains fragmented and uncertain. These problems of implementation and policy understanding are confirmed in two other studies in Burkina Faso . In Nouna and Ouargaye, two regions where the national exemption policy has been evaluated recently, the level of medical expenses is very similar to those in the partial exemption district of this study, Djibo . The medical expenses are usually higher than the designated user fees (900 F CFA), such as in Djibo where 50% of women (median) declared paying more than 1075 F CFA. The policy implementation gap appears to have more severe consequences in Dori and Djibo because the amount paid is much more than the one in Sebba. It represents at least 4 days of earnings for those who are living below the poverty line (46% of the population). This difference between Sebba and Dori could be explained by the fact that Sebba has a Chief Medical Officer with better leadership to implement an effective monitoring and control system to more effectively implement the total exemption policy. A study in Burkina Faso shows how the leadership of the District Chief Medical Officer (DCMO) could affect the performance of the District . This seems to be the case in Dori and Sebba. For example, in 2010 the DCMO of Sebba was able to find a scholarship to obtain a master’s degree and in 2012 the DCMO of Dori was transferred by the administration, reflecting that all health indicators are worse in Dori than Sebba over the last five years (see Table 4). However, further qualitative studies must be done to understand in depth this difference between the two districts. For example, it is crucial to analyse how the NGO monitoring and evaluation system responded to the different leadership in both districts. Finally, the results show that the policy instrument of the abolition of user fees is not enough; the implementation process as well as a thorough monitoring system to reduce the risk of implementation gap are essential [24, 25].
In addition, in Burkina Faso, the fixed-rate reimbursement of services represents a profound change to health administration practices, designed to reduce the work burden of health professionals. However, the administration in general in Burkina Faso is more bureaucratic and demands detailed proof for every health service delivered, even with a fixed-rate reimbursement system. This lack of alignment resulted in fixed-rate reimbursement under an actual-cost accounting system. Thus, one important weakness is that the accounting control system is not set up for fixed-rate reimbursement, and discussions are on-going to return to a system based on real expenses, as the actual costs for births are less than the fixed-rate reimbursement. Thus, the implementation gap can also be explained by this administrative conflict between practice and accountability. In fact, health professionals have a financial interest in reducing the real amount of used input to make a profit on the fixed-rate received for the service. Furthermore, despite relatively tight administrative controls, it seems that health workers have figured out how to take advantage of the system [23, 26]. It demonstrates once again the necessity to review policy instruments to improve its effectiveness.
The process of policy development and implementation has itself an important influence on effective implementation. In fact, the potential for a “no user fee” policy to translate into reduced mortality and morbidity for mothers and babies depends fundamentally on the effectiveness of its implementation. The NGO implemented a system of monitoring and control of the exemption system in all the health centres in Dori and Sebba. They also supported health centres in running and maintaining their facilities, by building the capacity of the healthcare and administrative staff as well as community health management committees. The NGO also initiated activities to raise community awareness of maternal health-related issues. They use a reimbursement form based on lump sum per delivery that coincides with a flat rate of 900 F CFA. However, findings demonstrate that there is a need for a strong monitoring and evaluation component to address problems related to partial and full policy implementation at the local and national levels, including effective and thorough dissemination of the policies to the communities and health workers .
Strengths and limitations
The adequacy of the study design and the degree of control exercised in the data gathering enhanced the internal validity. The random assignment of the sample and the control of external variables within the districts ensured the analysis of the change in the dependent variable (household expenses). In addition, at any given value of k, findings show the same type of association between the percentage of households with excessive spending and the group affiliation. This homogeneity enhances the reliability of the findings.
One limitation of this study is the potential for recall or memory bias. These measure biases can occur while collecting information about the extent and types of out-of-pocket expenditures by women/households for non-complicated institutional birthing services in the selected health centres. In order to reduce this type of systematic error regarding childbirth expenditures, researchers attempted to limit the period between interviews (May 2010) and time of birth to a maximum of 2 months. However, in cases where total number of deliveries during this period was not sufficient (< 50 women) the period of selection was extended up to 6 months prior to May 2010. This date extension was made only for the comparison district sample.
Another limitation is the lack of data in the districts of Dori and Sebba before the HELP intervention in 2008. In fact, we do not possess the information about the household expenses related to institutional delivery prior to the HELP pilot. Such data would have increased the internal validity of the study. Thus, in a context of natural experimentation, the case–control design is the best design to conduct such study.
The partial exemption district also had some limitation when it comes to analysing the istricts characteristics (Table 4). However, choices of districts for comparison were very limited. Therefore, there are challenges to the evaluation of public health policy interventions as natural experiments because of the lack of control over the study conditions . To reduce this challenge as much as possible, Djibo, which has characteristics most like to Dori and Sebba, was chosen for the study.