Advertisement

Analyzing the Financial Sustainability of User Fee Removal Policies: A Rapid First Assessment Methodology with a Practical Application for Burkina Faso

  • Jacky MathonnatEmail author
  • Martine Audibert
  • Salam Belem
Practical Application

Abstract

The purpose of this paper is to briefly present a methodological framework that does not require cumbersome investigations for a first assessment of the financial sustainability of policies aiming to remove or reduce healthcare user fees (the so-called free healthcare policy [FHCP]). This paper is organized in two main sections. The first analyzes the various possibilities available to finance an FHCP. Using several scenarios, it includes a special focus devoted to the calculus of what to consider when assessing the sustainability of expanding fiscal space for financing the FHCP. The second section relies on the current FHCP being implemented in Burkina Faso to illustrate a selection of specific issues raised in the methodological framework. The results suggest that sustainable FHCP financing is not outside the range of the government but does represent a significant challenge, as it will require, both currently and in the future, complex and delicate budget trade-offs at the highest governmental levels, regardless of other policy options to be considered.

Notes

Acknowledgements

This article is based on a research report that was prepared and funded by the Health Care Financing in Sub-Saharan African Collaborative Research Program of the African Economic Research Consortium (AERC; http://www.aercafrica.org) with the support of the FERDI (Fondation pour les Etudes et Recherches sur le Développement International). The authors thank two anonymous referees and the participants of the AERC’s Final Review Workshop (31 May–1 June 2018) and two anonymous referees from this journal for their comments and suggestions. However, the authors are solely responsible for the analyses presented in this article.

Author contributions

JM is the main author for the development of the methodology and the writing of the article. Each co-author contributed to the drafting of the paper and to the reflections and analyses presented therein.

Compliance with Ethical Standards

Conflict of interest

Jacky Mathonnat, Martine Audibert, and Salam Belem have no conflicts of interest that are directly relevant to the content of this review/study.

Supplementary material

40258_2019_506_MOESM1_ESM.docx (13 kb)
Supplementary material 1 (DOCX 12 kb)

References

  1. 1.
    WHO (2010) World health report, Geneva.Google Scholar
  2. 2.
    Akazili J, McIntyre D, Kanmiki EW, Gyapong J, Oduro A, Sankoh O, Ataguba JE. Assessing the catastrophic effects of out-of-pocket healthcare payments prior to the uptake of a nationwide health insurance scheme in Ghana. Glob Health Action. 2017;10(1):1289735.CrossRefGoogle Scholar
  3. 3.
    Khan J, Ahmed S, Evans TG. Catastrophic healthcare expenditure and poverty related to out-of-pocket payments for healthcare in Bangladesh—an estimation of financial risk protection of universal health coverage. Health Pol Plan. 2017;32(8):1102–10.CrossRefGoogle Scholar
  4. 4.
    Xu K, Evans DB, Kadama P, Nabyonga J, Ogwang Ogwal P, Nabukhonzo P, Aguilar AM. Understanding the impact of eliminating user fees: utilization and catastrophic health expenditures in Uganda. Soc Sci Med. 2006;62:866–76.CrossRefGoogle Scholar
  5. 5.
    Qin VM, Hone T, Millett C, et al. The impact of user charges on health outcomes in low-income and middle-income countries: a systematic review. BMJ Global Health. 2019;3:e001087.CrossRefGoogle Scholar
  6. 6.
    Wiysonge CS, Paulsen E, Lewin S, Ciapponi A, Herrera CA, Opiyo N, Pantoja T, Rada G, Oxman AD. Financial arrangements for health systems in low-income countries: an overviews of systematic reviews. Cochrane Data Base Syst Rev. 2017.  https://doi.org/10.1002/14651858.CD011084.pub2.Google Scholar
  7. 7.
    Lagarde M, Palmer N. The impact of user fees on health service utilization in low- and middle-income countries: how strong is the evidence? Bull World Health Organ. 2008;86:839–47.CrossRefGoogle Scholar
  8. 8.
    Nguyen HT, Zombré D, Ridde V, De Allegri M. The impact of reducing and eliminating user fees on facility-based delivery: a controlled interrupted time series in Burkina Faso. Health Pol Plan. 2018;33(8):948–56.CrossRefGoogle Scholar
  9. 9.
    Koné G, Audibert M, Lalou R, Lafarge H, Le Hesran J-Y. Subsidized antimalarial drugs in Dakar (Senegal): do the poor benefit? Études et Documents CERDI, ED 2017;11. halshs-01535112, version 1Google Scholar
  10. 10.
    Mladovsky P, Ba M. Removing user fees for health services: a multi-epistemological perspective on access inequities in Senegal. Soc Sci Med. 2017;188:91–9.CrossRefGoogle Scholar
  11. 11.
    Pyone T, Smith H, van den Broek N. Implementation of the free maternity services policy and its implications for health system governance in Kenya. BMJ Glob Health. 2017.  https://doi.org/10.1136/bmjgh-2016-000249.Google Scholar
  12. 12.
    Witter S, et al. Cost and impact of policies to remove and reduce fees for obstetric care in Benin, Burkina Faso, Mali and Morocco. Int J Equity Health. 2016;15(1):123.  https://doi.org/10.1186/s12939-016-0412-y.CrossRefGoogle Scholar
  13. 13.
    McKinnon B, Harper S, Kaufman JS. Who benefits from removing user fees for facility-based delivery services? Evidence of socioeconomic differences from Ghana, Senegal, and Sierra Leone. Soc Sci Med. 2015;2(135):117–23.CrossRefGoogle Scholar
  14. 14.
    Ridde V. From institutionalization of user fees to their abolition in West Africa: a story of pilot projects and public policies. BMC Health Serv Res. 2015;15(3):S6.  https://doi.org/10.1186/1472-6963-15-S3-S6.CrossRefGoogle Scholar
  15. 15.
    Toure L. User fee exemption policies in Mali: sustainability jeopardized by the malfunctioning of the health system. BMC Health Serv Res. 2015;15(Suppl. 3):S8.  https://doi.org/10.1186/1472-6963-15-S3-S8.CrossRefGoogle Scholar
  16. 16.
    Dzakpasu S, Powell-Jackson T, Campbell OM. Impact of user fees on maternal health service utilization and related health outcomes: a systematic review. Health Pol Plan. 2014;29(2):137–50.  https://doi.org/10.1093/heapol/czs142 (Epub 2013 Jan 30).CrossRefGoogle Scholar
  17. 17.
    Ridde V, Robert E, Meessen B. A literature review of the disruptive effects of user fee exemption policies on health systems. BMC Public Health. 2012;12:289.10.CrossRefGoogle Scholar
  18. 18.
    Meessen B, Hercot D, Noirhomme M, Ridde V, Tibouti A, Tashobya C, et al. Removing user fees in the health sector: a review of policy processes in six sub-Saharan African countries. Health Pol Plan. 2011;26(2):ii16–29.Google Scholar
  19. 19.
    Walugembe D, Sibbald S, Le Ber M, Kothari A. Sustainability of public health interventions: where are the gaps? Health Res Pol Syst. 2019;17:8.CrossRefGoogle Scholar
  20. 20.
    Moore JE, Mascarenhas A, Bain J, Straus SE. Developing a comprehensive definition of sustainability. Implement Sci. 2017;12(1):110.  https://doi.org/10.1186/s13012-017-0637-1.CrossRefGoogle Scholar
  21. 21.
    Birch S, Murphy GT, MacKenzie A, Cumming J. In place of fear: aligning health care planning with system objectives to achieve financial sustainability. J Health Serv Res Pol. 2015;20(2):109–14.  https://doi.org/10.1177/1355819614562053 (Epub 2014 Dec 11).CrossRefGoogle Scholar
  22. 22.
    Liaropoulos L, Goranitis I. Health care financing and the sustainability of health systems. Int J Equity Health. 2015;14:80.  https://doi.org/10.1186/s12939-015-0208-5.CrossRefGoogle Scholar
  23. 23.
    WHO, Global expenditure data base. https://apps.who.int/nha/database
  24. 24.
    WHO-GTZ, SimIns health financing policy tool. https://www.who.int/health_financing/tools/simins/en/
  25. 25.
    Okungu V, Chuma J, McIntyre D. The cost of free health care for all Kenyans: assessing the financial sustainability of contributory and non-contributory financing mechanisms. Int J Equity Health. 2017;16:39.  https://doi.org/10.1186/s12939-017-0535-.CrossRefGoogle Scholar
  26. 26.
    Heller P. Understanding the fiscal space, IMF Policy Discussion Paper, PDP 05/04. 2005.Google Scholar
  27. 27.
    Mathonnat J, Petitfour L, Tapsoba Y. 2017. Espace budgétaire pour la santé—mesure, évolution, déterminants, Report for WHO and Agence Française de Développement, p 107.Google Scholar
  28. 28.
    Mathonnat J, Audibert M. 2016. Fonds fiduciaires et programmes verticaux : quelles contributions aux politiques sectorielles? Revue de la littérature et exemple du secteur de la santé, Research Paper Serie 20, Agence Française de Développement, p 84.Google Scholar
  29. 29.
    Barroy H, Sparkes S, Dale E, Mathonnat J. Can low-and-middle income countries increase domestic fiscal space for health: a mixed-methods approach to assess possible sources of expansion. Health Syst Reform. 2018;4(2):1–13.Google Scholar
  30. 30.
    Reich MR, Harris J, Ikegami N, Maeda A, Cashin C, Araujo EC, Takemi K, Evans TG. Moving towards universal health coverage: lessons from 11 country studies. Lancet. 2016;387(10020):811–6.CrossRefGoogle Scholar
  31. 31.
    Shan L, Wu Q, Liu C, Li Y, Cui Y, Liang Z, Hao Y, Liang L, Ning N, Ding D, Pan Q, Han L. Perceived challenges to achieving universal health coverage: a cross-sectional survey of social health insurance managers/administrators in China. BMJ Open. 2017;7(5):e014425.CrossRefGoogle Scholar
  32. 32.
    IMF. 2017. Burkina Faso: Seventh Review Under the Extended Credit Facility Arrangement, Staff Report, Country Report No. 17/222, July 18.Google Scholar
  33. 33.
    WHO Global Health Observatory. https://www.who.int/gho/en/
  34. 34.
    Ministère de la Santé Publique. Stratégie nationale de gratuité des soins chez la femme enceinte, des accouchements, de la césarienne, et des autres SONU. Ougadougou, Burkina Faso: Mimeo; 2016 (unpublished documents).Google Scholar
  35. 35.
    Ministère de la Santé Publique. Stratégie nationale d’exemption de paiement des soins curatifs pour les enfants de moins de 5 ans. Ougadougou, Burkina Faso: Mimeo; 2016 (unpublished documents).Google Scholar
  36. 36.
    Ministère de la Santé Publique. Stratégie nationale de gratuité du dépistage et de destruction des lésions précancéreuses du col de l’utérus et de l’examen clinique du sein. Ougadougou, Burkina Faso: Mimeo; 2016 (unpublished documents).Google Scholar
  37. 37.
    Ministère de la Santé Publique. Manuel d’éxécution des stratégies de gratuité au Burkina Faso. Ougadougou, Burkina Faso: Mimeo; 2016 (unpublished documents).Google Scholar
  38. 38.
    Ministère de la Santé publique. Politique nationale des mesures de gratuité des soins – Stratégie de mise en oeuvre 2018–2022. Ougadougou, Burkina Faso: Mimeo; 2017 (unpublished documents).Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Jacky Mathonnat
    • 1
    Email author
  • Martine Audibert
    • 2
  • Salam Belem
    • 3
  1. 1.University Clermont Auvergne and FERDI (Fondation pour les Etudes et Recherches sur le Développement International)Clermont-FerrandFrance
  2. 2.University Clermont Auvergne, CERDI (Centre d’Etudes et de Recherches sur le Développement International)Clermont-FerrandFrance
  3. 3.Sahel Demographic Dividend (SWEDD), Health Development Support ProgramMinistry of HealthOuagadougouBurkina Faso

Personalised recommendations