Cost and impact of policies to remove and reduce fees for obstetric care in Benin, Burkina Faso, Mali and Morocco
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Date
2016-08-02Author
Witter, Sophie
Boukhalfa, C.
Cresswell, Jenny A.
Daou, Z.
Filippi, Veronique
Ganaba, Rasman
Goufodji, Sourou B.
Lange, Isabelle
Marchal, Bruno
Richard, Fabienne
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Witter, S., Boukhalfa, C., Cresswell, J., Daou, Z., Filippi, V., Ganaba, R., Goufodji, S., Lange, I., Marchal, B. & Richard, F. (2016) Cost and impact of policies to remove and reduce fees for obstetric care in Benin, Burkina Faso, Mali and Morocco, International Journal for Equity in Health, 15, pp. 123-142.
Abstract
Background: Across the Africa region and beyond, the last decade has seen many countries introducing policies
aimed at reducing financial barriers to obstetric care. This article provides evidence of the cost and effects of
national policies focussed on improving financial access to caesarean and facility deliveries in Benin, Burkina Faso,
Mali and Morocco.
Methods: The study uses a comparative case study design with mixed methods, including realist evaluation
components. This article presents results across 14 different data collection tools, used in 4-6 research sites in each
of the four study countries over 2011-13. The methods included: document review; interviews with key informants;
analysis of secondary data; structured extraction from medical files; cross-sectional surveys of patients and staff;
interviews with patients and observation of care processes.
Results: The article finds that the policies have contributed to continued increases in skilled birth attendance and
caesarean sections and a narrowing of inequalities in all four countries, but these trends were already occurring so
a shift cannot be attributed solely to the policies. It finds a significant reduction in financial burdens on households
after the policy, suggesting that the financial protection objectives may have been met, at least in the short term,
although none achieved total exemption of targeted costs. Policies are domestically financed and are potentially
sustainable and efficient, and were relatively thoroughly implemented. Further, we find no evidence of negative
effects on technical quality of care, or of unintended negative effects on untargeted services.
Conclusions: We conclude that the policies were effective in meeting financial protection goals and probably
health and equity goals, at sustainable cost, but that a range of measures could increase their effectiveness and
equity. These include broadening the exempted package (especially for those countries which focused on
caesarean sections alone), better calibrated payments, clearer information on policies, better stewardship of the
local health system to deal with underlying systemic weaknesses, more robust implementation of exemptions for
indigents, and paying more attention to quality of care, especially for newborns.