Financial accessibility and user fee reforms for maternal- health care in five sub-Saharan countries: a quasi-experimental analysis

Objectives: Evidence on whether removing fees benefits the poorest is patchy and weak. The aim of this paper is to measure the impact of user fee reforms on the probability of giving birth in an institution or receiving a caesarean section (CS) in Ghana, Burkina Faso, Zambia, Cameroon and Nigeria for the poorest strata of the population. Setting: Women’s experience of user fees in five African countries. Primary and secondary outcome measures: Using quasi experimental regression analysis we tested the impact of user fee reforms on facilities’ births and CS differentiated by wealth, education and residence in Burkina Faso and Ghana. Mapping of the literature followed by key informant interviews are used to verify details of reform implementation and to confirm and support our countries' choice. Participants: We analysed data from consecutive surveys in five countries: two case countries that experienced reforms (Ghana and Burkina Faso) in contrast to three that did not experience reforms (Zambia, Cameroon, Nigeria). Results: User fee reforms are associated with a significant percentage of the increase in access to facility births (27 percentage points) and to a much lesser extent to CS (0.7 percentage points). Poor (but not the poorest) and non-educated women and those in rural areas benefitted the most from the reforms. User fees reforms have had a higher impact in Burkina Faso compared to Ghana. Conclusions: Findings show a clear positive impact on access when user fees are removed but limited evidence for improved availability of CS for those most in need. More women from rural areas and from lower socioeconomic backgrounds give birth in health facilities after fee reform. Speed and quality of implementation might be the key reason behind the differences between the two case countries. This calls for more research into the impact of reforms on quality of care.