Advertisement

The European Journal of Health Economics

, Volume 16, Issue 1, pp 55–64 | Cite as

The impact of user fee removal policies on household out-of-pocket spending: evidence against the inverse equity hypothesis from a population based study in Burkina Faso

  • V. RiddeEmail author
  • I. Agier
  • A. Jahn
  • O. Mueller
  • J. Tiendrebéogo
  • M. Yé
  • M. De Allegri
Original Paper

Abstract

Background

User fee removal policies have been extensively evaluated in relation to their impact on access to care, but rarely, and mostly poorly, in relation to their impact on household out-of-pocket (OOP) spending. This paucity of evidence is surprising given that reduction in household economic burden is an explicit aim for such policies. Our study assessed the equity impact on household OOP spending for facility-based delivery of the user fee reduction policy implemented in Burkina Faso since 2007 (i.e. subsidised price set at 900 Communauté Financière Africaine francs (CFA) for all, but free for the poorest). Taking into account the challenges linked to implementing exemption policies, we aimed to test the hypothesis that the user fee reduction policy had favoured the least poor more than the poor.

Methods

We used data from six consecutive rounds (2006–2011) of a household survey conducted in the Nouna Health District. Primary outcomes are the proportion of households being fully exempted (the poorest 20 % according to the policy) and the actual level of household OOP spending on facility-based delivery. The estimation of the effects relied on a Heckman selection model. This allowed us to estimate changes in OOP spending across socio-economic strata given changes in service utilisation produced by the policy.

Findings

A total of 2,316 women reported a delivery between 2006 and 2011. Average household OOP spending decreased from 3,827 CFA in 2006 to 1,523 in 2011, without significant differences across socio-economic strata, neither in terms of households being fully exempted from payment nor in terms of the amount paid. Payment remained regressive and substantially higher than the stipulated 900 CFA.

Conclusions

The Burkinabè policy led to a significant and sustained reduction in household OOP health spending across all socio-economic groups, but failed to properly target the poorest by ensuring a progressive payment system.

Keywords

User fees Abolition Maternal health Policy Out-of-pocket spending Burkina Faso 

JEL Classification

C01 I14 I18 I38 Z18 

Supplementary material

10198_2013_553_MOESM1_ESM.png (23 kb)
Household Wealth Index repartition by location of delivery (PNG 23 kb)

References

  1. 1.
    Ridde, V., Morestin, F.: A scoping review of the literature on the abolition of user fees in health care services in Africa. Health Policy Plan 26(1), 1–11 (2011)PubMedCrossRefGoogle Scholar
  2. 2.
    Rodin, J., De Ferranti, D.: Universal health coverage: the third global health transition? Lancet 380, 861–862 (2012)PubMedCrossRefGoogle Scholar
  3. 3.
    Sambo, L., Kirigia, J., Ki-Zerbo, G.: Perceptions and viewpoints on proceedings of the Fifteenth Assembly of Heads of State and Government of the African Union Debate on Maternal, Newborn and Child Health and Development, 25–27 July 2010, Kampala Uganda. BMC Proc. 5(Suppl 5), S1 (2011)PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    De Brouwere, V., Richard, F., Witter, S.: Access to maternal and perinatal health services: lessons from successful and less successful examples of improving access to safe delivery and care of the newborn. Trop. Med. Int. Health 15(8), 901–909 (2010)Google Scholar
  5. 5.
    Gwatkin, D.: Ergo: universal health coverage: friend or foe of health equity? Lancet 377(9784), 2160–2161 (2011)PubMedCrossRefGoogle Scholar
  6. 6.
    Castro-Leal, F., Dayton, J., Demery, L., Mehra, K.: Public spending on health care in Africa: do the poor benefit? Bull. World Health Organ. 78(1), 66–74 (2000)PubMedCentralPubMedGoogle Scholar
  7. 7.
    Lagarde, M., Palmer, N.: The impact of user fees on access to health services in low- and middle-income countries. Cochrane Database Syst. Rev. 4, CD009094 (2011). doi: 10.1002/14651858.CD009094 PubMedGoogle Scholar
  8. 8.
    Dzakpasu, S., Powell-Jackson, T., Campbell, O.M.R.: Impact of user fees on maternal health service utilization and related health outcomes: a systematic review. (2013). Health Policy Plan. doi:  10.1093/heapol/czs142
  9. 9.
    Asante, F.A., Chikwama, C., Daniels, A., Armar-Klemesu, M.: Evaluating the economic outcomes of the policy of fee exemption for maternal delivery care in Ghana. Ghana Med. J. 41(3), 110–117 (2007)PubMedCentralPubMedGoogle Scholar
  10. 10.
    De Allegri, M., Ridde, V., Louis, V., Sarker, M., Tiéndrebeogo, J., Ye, M., Müller, O., Jahn, A.: The impact of targeted subsidies for facility-based delivery on access to care and equity—evidence from a population-based study in rural Burkina Faso. J. Public Health Policy 33(4), 439–453 (2012)PubMedCrossRefGoogle Scholar
  11. 11.
    Ridde, V., Kouanda, S., Bado, A., Bado, N., Haddad, S.: Reducing the medical cost of deliveries in Burkina Faso is good for everyone, including the poor. PLoS One 7(3), e33082 (2012). doi: 10.1371/journal.pone.0033082 PubMedCentralPubMedCrossRefGoogle Scholar
  12. 12.
    Xu, K., Evans, D.D., Kadama, P., Nabyonga, J., Ogwang Ogwal, P., Nabukhonzo, P., Aguilar, A.M.: Understanding the impact of eliminating user fees: utilization and catastrophic health expenditures in Uganda. Soc. Sci. Med. 62, 866–876 (2006)PubMedCrossRefGoogle Scholar
  13. 13.
    Nabyonga Orem, J., Mugisha, F., Kirunga, C., Macq, J., Criel, B.: Abolition of user fees: the Uganda paradox. Health Policy Plan 26(Suppl 2), 41–51 (2011)Google Scholar
  14. 14.
    Deininger, K., Mpuga, P.: Economic and welfare impact of the abolition of health user fees: evidence from Uganda. J. Afr. Econ. 14(1), 55–91 (2005)CrossRefGoogle Scholar
  15. 15.
    Sié, A., Louis, V., Gbangou, A., Muller, O., Niamba, L., Stieglbauer, G., Yé, M., Kouyaté, B., Saueborn, R., Becher, H.: The Health and Demographic Surveillance System (HDSS) in Nouna, Burkina Faso, 1993–2007. Glob. Health Action 3(5284), 5284 (2010)Google Scholar
  16. 16.
    Ministère de la Santé: Stratégie nationale de subvention des accouchements et des soins obstétricaux et néonataux d’urgence au Burkina Faso, p. 65. Ministère de la Santé, Ouagadougou (2006)Google Scholar
  17. 17.
    Ridde, V., Richard, F., Bicaba, A., Queuille, L., Conombo, G.: The national subsidy for deliveries and emergency obstetric care in Burkina Faso. Health Policy Plan 26(Suppl 2), ii30–ii40 (2011)PubMedGoogle Scholar
  18. 18.
    Belaid, L., Ridde, V.: An implementation evaluation of a policy aiming to improve financial access to maternal health care in Djibo district, Burkina Faso. BMC Pregnancy Childbirth 12, 143 (2012). doi: 10.1186/1471-2393-12-143 PubMedCentralPubMedCrossRefGoogle Scholar
  19. 19.
    Victora, C.G., Vaughan, J.P., Barros, F.C., Silva, A.C., Tomasi, E.: Explaining trends in inequities: evidence from Brazilian child health studies. Lancet 356(9235), 1093–1098 (2000)PubMedCrossRefGoogle Scholar
  20. 20.
    De Allegri, M., Louis, V., Tiendrébeogo, J., Souares, A., Yé, M., Tozan, Y., Jahn, A., Mueller, O.: Moving towards universal coverage with malaria control interventions: achievements and challenges in rural Burkina Faso. Int. J. Health Plan. Manag. 28(1), 102–121 (2012)CrossRefGoogle Scholar
  21. 21.
    De Allegri, M., Ridde, V., Louis, V.R., Sarkera, M., Tiendrebéogoc, J., Yé, M., Müller, O., Jahn, A.: Determinants of utilisation of maternal care services after the reduction of user fees: a case study from rural Burkina Faso. Health Policy 99(3), 210–218 (2010)PubMedCrossRefGoogle Scholar
  22. 22.
    Muller, O., De Allegri, M., Becher, H., Tiendrebogo, J., Beiersmann, C., Ye, M., Kouyate, B., Sie, A., Jahn, A.: Distribution systems of insecticide-treated bed nets for malaria control in rural Burkina Faso: cluster-randomized controlled trial. PLoS One 3(9), e3182 (2008). doi: 10.1371/journal.pone.0003182 PubMedCentralPubMedCrossRefGoogle Scholar
  23. 23.
    Milligan, P., Nije, A., Bennett, S.: Comparison of two cluster sampling methods for health surveys in developing countries. Int. J. Epidemiol. 33(3), 476–496 (2004)CrossRefGoogle Scholar
  24. 24.
    Hausman, J.: Sample selection bias as a specification error. Econometrica 47, 153–161 (1979)CrossRefGoogle Scholar
  25. 25.
    Filmer, D., Pritchett, L.H.: Estimating wealth effects without expenditure data–or tears: an application to educational enrolments in states of India. Demography 38(1), 115–132 (2001)PubMedGoogle Scholar
  26. 26.
    Su, T., Pokhrel, S., Gbangou, A., Flessa, S.: Determinants of household health expenditure on western institutional health care. Eur. J. Health Econ. 7(3), 199–207 (2006)PubMedCrossRefGoogle Scholar
  27. 27.
    Hajizadeh, M., Nghiem, H.: Out-of-pocket expenditures for hospital care in Iran: who is at risk of incurring catastrophic payments? Int. J. Health Care Finance Econ. 11(4), 267–285 (2011)PubMedCrossRefGoogle Scholar
  28. 28.
    Heckman, J.: Sample selection bias as a specification error. Econometrica 47, 153–161 (1979)CrossRefGoogle Scholar
  29. 29.
    Su, T., Flessa, S.: Determinants of household direct and indirect costs: an insight for health-seeking behaviour in Burkina Faso. Euro. J. Health Econ. 14(1), 75–84 (2013)CrossRefGoogle Scholar
  30. 30.
    Wirtz, V., Santa-Ana-Tellez, Y., Servan-Mori, E., Avila-Burgos, L.: Heterogeneous effects of health insurance on out-of-pocket expenditure on medicines in Mexico. Value Health. 15(5), 593–603 (2012)PubMedCrossRefGoogle Scholar
  31. 31.
    Porterfield, S., DeRigne, L.: Medical home and out-of-pocket medical costs for children with special health care needs. Pediatrics 128(5), 892–900 (2011)PubMedCrossRefGoogle Scholar
  32. 32.
    Ridde, V., Queuille, L., Atchessi, N., Samb, O., Heinmüller, R., Haddad, S.: A user fees abolition experimentation evaluation for vulnerable groups in Burkina Faso. Field Actions Sci. Rep. Special Issue 8 (2012). http://factsreports.revues.org/1758
  33. 33.
    Ridde, V., Diarra, A.: 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, 89 (2009)PubMedCentralPubMedCrossRefGoogle Scholar
  34. 34.
    Carroll, C., Patterson, M., Wood, S., Booth, A., Rick, J., Balain, S.: A conceptual framework for implementation fidelity. Implement Sci. 2, 40 (2007). doi: 10.1186/1748-5908-2-40 PubMedCentralPubMedCrossRefGoogle Scholar
  35. 35.
    Witter, S., Dieng, T., Mbengue, D., Moreira, I., de Brouwere, V.: The national free delivery and caesarean policy in Senegal: evaluating process and outcomes. Health Policy Plann. 25(5), 384–392 (2010). doi: 10.1093/heapol/czq013 Google Scholar
  36. 36.
    Ridde, V., Kouanda, S., Yameogo, M., Kadio, K., Bado, A.: Why do women pay more than they should? A mixed methods study of the implementation gap in a policy to subsidize the costs of deliveries in Burkina Faso. Eval. Progr. Plann. 36(1), 145–152 (2012)CrossRefGoogle Scholar
  37. 37.
    Witter, S., Khalid Mousa, K., Abdel-Rahman, M., Hussein Al-Amin, R., Saed, M.: Removal of user fees for caesareans and under-fives in northern Sudan: a review of policy implementation and effectiveness. Int. J. Health Plan. Manag. (2012). doi: 10.1002/hpm.2146 Google Scholar
  38. 38.
    de Olivier Sardan, J.-P., Ridde, V.: Les contradictions des politiques publiques. Un bilan des mesures d’exemption de paiement des soins au Burkina Faso, au Mali et au Niger. Afr. Contemp. 243(3), 13–32 (2012)Google Scholar
  39. 39.
    Ridde, V.: “The problem of the worst-off is dealt with after all other issues”: the equity and health policy implementation gap in Burkina Faso. Soc. Sci. Med. 66, 1368–1378 (2008)PubMedCrossRefGoogle Scholar
  40. 40.
    Gilson, L., Kalyalya, D., Kuchler, F., Lake, S., Organa, H., Ouendo, M.: The equity impacts of community financing activities in three African countries. Int. J. Health Plann. Manag. 15, 291–317 (2000)CrossRefGoogle Scholar
  41. 41.
    The Global Campaign for the Health Millennium Development Goals: leading by example—protecting the most vulnerable during the economic crisis, p. 59. Office of the Prime Minister of Norway, Oslo (2009)Google Scholar
  42. 42.
    Victora, C., Barros, A., Axelson, H., Bhutta, Z., Chopra, M., França, G., Kerber, K., Kirkwood, B., Newby, H., Ronsmans, C., Boerma, J.: How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys. Lancet 380(9848), 1149–1156 (2012)PubMedCrossRefGoogle Scholar
  43. 43.
    Ridde, V., Yaogo, M., Kafando, Y., Kadio, K., Ouedraogo, M., Bicaba, A., Haddad, A.: Targeting the worst-off for free health care: a process evaluation in Burkina Faso. Eval. Progr. Plann. 34(4), 333–342 (2011)CrossRefGoogle Scholar
  44. 44.
    Haddad, S., Ridde, V., Bekele, Y., Queuille, L.: Increased subsidies for delivery costs translate into more women giving birth in health centres. http://www.equitesante.org/helpburkina-en/policy-briefs/ (2011). Accessed 23 Dec 2013
  45. 45.
    Lagarde, M., Barroy, H., Palmer, N.: Assessing the effects of removing user fees in Zambia and Niger. J. Health Serv. Res. Policy 17(1), 30–36 (2012)PubMedCrossRefGoogle Scholar
  46. 46.
    WHO: World Health Statistics 2013, p. 172. World Health Organization, Geneva (2013)Google Scholar
  47. 47.
    Dzakpasu, S., Soremekun, S., Manu, A., ten Asbroek, G., Tawiah, C., Hurt, L., Fenty, J., Owusu-Agyei, S., Hill, Z., Campbell, O.M.R., Kirkwood, B.R.: Impact of free delivery care on health facility delivery and insurance coverage in Ghana’s Brong Ahafo region. PLoS One 7(11), e49430 (2012). doi: 10.1371/journal.pone.0049430 PubMedCentralPubMedCrossRefGoogle Scholar
  48. 48.
    WHO: The world health report–Health systems financing: the path to universal coverage. World Health Organization, Geneva (2010)Google Scholar
  49. 49.
    IRSS: Évaluation des besoins en soins obstétricaux et néonataux d’urgence, couplée à la cartographie de l’offre de soins en santé de la reproduction au Burkina Faso. Rapport provisoire, p. 346. Institut de recherche en sciences de la santé-CNRST, Ouagadougou (2010)Google Scholar
  50. 50.
    Mathauer, I., Carrin, G.: The role of institutional design and organizational practice for health financing performance and universal coverage. Health Policy 99, 183–192 (2011)PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • V. Ridde
    • 1
    Email author
  • I. Agier
    • 4
  • A. Jahn
    • 2
  • O. Mueller
    • 2
  • J. Tiendrebéogo
    • 3
  • M. Yé
    • 3
  • M. De Allegri
    • 2
  1. 1.Département de Médecine Sociale et Préventive, Montréal School of Public Health, Centre de recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM)Université de MontréalMontréalCanada
  2. 2.Institute of Public HealthUniversity of HeidelbergHeidelbergGermany
  3. 3.Centre de Recherche en Santé de NounaNounaBurkina Faso
  4. 4.Centre de recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM)Université de MontréalMontréalCanada

Personalised recommendations