User fee exemptions and equity in access to caesarean sections: an analysis of patient survey data in Mali
Little 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.
We 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.
We 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.
While fee exemptions remove important financial barriers to accessing priority maternal health services, they are insufficient to ensure equal access among wealth groups.
- James, C, Hanson, K, McPake, B, Balabanova, D, Gwatkin, D, Hopwood, I, Kirunga, C, Knippenberg, R, Meessen, B, Morris, S, Preker, A, Souteyrand, Y, Tibouti, A, Villeneuve, P, Xu, K (2006) To retain or remove user fees? Reflections on the current debate in low-and middle-income countries. London School of Hygiene and Tropical Medicine. Appl Health Econ Health Policy 5: pp. 137-153 CrossRef
- Lagarde, M, Palmer, N (2008) The impact of user fees on access to health services in low-and middle-income countries. Bull World Health Organ 86: pp. 839-848 CrossRef
- Nabyonga, J, Desmet, M, Karamagi, H, Kadama, PY, Omaswa, FG, Walker, O (2005) Abolition of cost-sharing is pro-poor: evidence from Uganda. Health Policy Plan 20: pp. 100-108 CrossRef
- Ridde, V, Diarra, A (2009) A process evaluation of user fees abolition for pregnant women and children under five years in two districts in Niger (West Africa). BMC Health Serv Res 9: pp. 89 CrossRef
- Abdu, Z, Mohammed, Z, Bashier, I, Eriksson, B (2004) The impact of user fee exemption on service utilization and treatment seeking behavior: the case of malaria in Sudan. Int J Health Plann Manage 19: pp. S95-S106 CrossRef
- Uzochukwu, B, Onwujekwe, O, Eriksson, B (2004) Inequity in the Bamako initiative programme: implications for the treatment of malaria in south-east Nigeria. Int J Health Plann Manage 19: pp. S107-S116 CrossRef
- Pitchforth, E, van Teijlingen, E, Graham, W, Fitzmaurice, A (2007) Development of a proxy wealth index for women utilizing emergency obstetric care in Bangladesh. Health Policy Plan 22: pp. 311-319 CrossRef
- Enquête Démographique et de Santé du Mali 2006 (EDSM-IV). CPS/DNSI and Macro International Inc, Enquête Démographique et de Santé du Mali 2006 (EDSM-IV), Calverton, MD
- Paxton, A, Maine, D, Freedman, L, Fry, D, Lobis, S (2005) The evidence for emergency obstetric care. Int J Gynecol Obstet 88: pp. 181-193 CrossRef
- Campbell, OM, Graham, WJ (2006) Strategies for reducing maternal mortality: getting on with what works. Lancet 368: pp. 1284-1299 CrossRef
- Indicators to monitor maternal health goals. Report of a Technical Working Group. WHO, Geneva
- Diaby, M (2006) Etude de la Césarienne à la Maternité du Centre de Santé de Référence de la Commune I du District de Bamako. Thesis.
- Diallo, O (2006) La Césarienne Aspects Épidémiologiques, Cliniques, Socio-économiques et Pronostic Materno-Foetal à L'Hôpital Régional de Gao.
- Diarra, MG (2006) Etude de la Césarienne à la Maternité de l’Hôpital Nianankoro Fomba de Ségou.
- Guirro, B (2006) Etude de la Césarienne dans le Service de Gynéco Obstétrique de L’Hôpital Régional Sominé Dolo de Mopti.
- Improving access to life-saving maternal health services: the effects of removing user fees for caesareans in Mali. Abt Associates Inc, Bethesda, MD
- Ridde, V, Morestin, F (2010) A scoping review of the literature on the abolition of user fees in health care services in Africa. Health Policy Plan 26: pp. 1-11 CrossRef
- Measure DHS-Mali: Standard DHS, 2006 Dataset. http://www.measuredhs.com/data/dataset/Mali_Standard-DHS_2006.cfm
- Rutstein, SO, Johnson, K (2004) The DHS wealth index. DHS Comparative Reports No. 6. ORC Macro, Calverton, MD
- Filmer, D, Pritchett, LH (2001) Estimating wealth effect without expenditure data – or tears: an application to educational enrollments in states of India. Demography 38: pp. 115-132
- User fee exemptions and equity in access to caesarean sections: an analysis of patient survey data in Mali
- Open Access
- Available under Open Access This content is freely available online to anyone, anywhere at any time.
International Journal for Equity in Health
- Online Date
- August 2012
- Online ISSN
- BioMed Central
- Additional Links
- User fees
- Caesarean sections
- Author Affiliations
- 1. Associate/Economist, Abt Associates Inc, 4550 Montgomery Ave, Suite 800 North, Bethesda, MD, 20814, USA
- 2. Senior Associate/Health Economist, Abt Associates Inc, 4550 Montgomery Ave, Suite 800 North, Bethesda, MD, 20814, USA
- 3. Senior Advisor & Team Leader, Abt Associates, Bamako, MALI