Table 4 Main characteristics of the included studies
From: User fee policies and women’s empowerment: a systematic scoping review
First author (year) | Country and setting | Objective | User fee policy in place | Type of study and participants | Main conclusion about the relation between user fee policies and women’s empowerment |
|---|---|---|---|---|---|
Cornish et al. (2019) [41] | Sierra Leone | To explore the relationship between women’s economic empowerment and health decision-making | Free health care for pregnant women, breastfeeding mothers and children < 5 | Qualitative | Indirect relation |
10 rural communities | In-depth interviews N = 29 women | Economic interventions support women’s economic empowerment, but women’s social empowerment, alongside economic empowerment, needs consideration | |||
Johnson et al. (2012) [35] | Mali | To identify consequences of user fees on gender inequality, food insecurity and household decision-making | Fees are charged at point of care for consultations, diagnostic, medications and care services, excepted a few services that are free of charge (caesarean sections, HIV testing and treatment, malaria treatment) | Qualitative | Direct relation |
Peri-urban areas | Ethnographic life history interviews | User fees reduced agency for women in health care decision-making | |||
N = 24 women | |||||
Kabia et al. (2018) [36] | Kenya | To explore how gender disability and poverty interact and influence how poor women in Kenya benefit from pro-poor financing policies that target them. | (i) Free maternity policy | Qualitative | Indirect relation |
County A (urban) | (ii) abolition of user fees in public primary healthcare facilities | In-depth interviews | Poor, disabled women continued to experience disempowerment within the health system despite free health care | ||
County B (rural) | N = 11 women with disabilities living in poverty | ||||
(iii) health insurance subsidy programme | |||||
Samb et al. (2018)a [37] | Burkina Faso | To examine the effect of free healthcare on women’s capability | Reproductive and maternal care (including emergency obstetric and neonatal services) are free of charge | Qualitative | Direct relation |
Rural areas in 3 health districts (Dori, Sebba, Ouargaye) | Semi-structured interviews, documentary analysis and non-participant observation | Free healthcare contributed to strengthen women’s capability related to healthcare | |||
N = 64 (40 women, 16 members of a health center management committee and 8 healthcare workers) | |||||
Samb et al. (2015)a [43] | Burkina Faso | To examine the effect of free healthcare on women’s capability | Reproductive and maternal care (including emergency obstetric and neonatal services) are free of charge | Qualitative | Direct relation |
Rural areas in 3 health districts (Dori, Sebba, Ouargaye) | Semi-structured interviews, documentary analysis and non-participant observation | Free healthcare contributed to strengthen women’s capability related to healthcare | |||
N = 64 (40 women, 16 members of a health center management committee and 8 healthcare workers) | |||||
Samb et al. (2013)a [42] | Burkina Faso | To examine the effect of free healthcare on women’s capability | Reproductive and maternal care (including emergency obstetric and neonatal services) are free of charge | Qualitative | Direct relation |
Rural areas in 3 health districts (Dori, Sebba, Djibo) | Semi-structured interviews | Free healthcare contributed to strengthen women’s capability related to healthcare | |||
N unknown | |||||
Treacy et al. (2015)b [38] | Sierra Leone | To explore the perceptions and decision-making processes of women related to childbirth in a context of free healthcare. | Free health care for pregnant women, breastfeeding mothers and children < 5 | Qualitative | Indirect relation |
2 villages in the Northern Province | Focus groups and in-depth interviews N = 71 (44 women and 27 men) | Decision-making processes during childbirth are dynamic, intricate and need to be understood within broader social context. For this reason, free healthcare initiatives have limited impact. | |||
Treacy et al. (2018)b [39] | Sierra Leone | To explore who and what influences the decisions made by women, and how the position of women in society impact upon these processes in a context of free healthcare | Free health care for pregnant women, breastfeeding mothers and children < 5 | Qualitative | Indirect relation |
2 villages in the Northern Province | Focus groups and in-depth interviews | Gender inequities remain despite the introduction of free health care. | |||
N = 61 (number of women unknown) | Decisions during childbirth are influenced by constraints of poverty and other social determinants (unequal power, social norms, etc.) | ||||
Witter et al. (2017) [40] | India (secondary data analysis) | To explore which financing reforms are likely to be the most effective at accelerating progress toward universal health coverage while at the same time addressing gender inequities | Different health-financing policies including user fees, health insurance, vouchers and conditional cash transfers | Rapid review of health literature and case study | Indirect relation |
Public financing mechanisms such as user fee abolition are not sufficient to reduce gender inequities because they do no tackle the social determinants that undermine access to healthcare |