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Who benefits from removing user fees for facility-based delivery services? Evidence on socioeconomic differences from Ghana, Senegal and Sierra Leone

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  • McKinnon, Britt
  • Harper, Sam
  • Kaufman, Jay S.
Abstract
Coverage of skilled delivery care has been increasing across most low-income countries; however, it remains far from universal and is very unequally distributed according to socioeconomic position. In an effort to increase coverage of skilled delivery care and reduce socioeconomic inequalities, governments of several countries in sub-Saharan Africa have recently adopted policies that remove user fees for facility-based delivery services. There is little rigorous evidence of the impact of these policies and few studies have examined effects on socioeconomic inequalities. This study investigates the impact of recent delivery fee exemption policies in Ghana, Senegal, and Sierra Leone on socioeconomic differences in the use of facility-based delivery services. Using Demographic and Health Survey data from nine sub-Saharan African countries, we evaluated the user fee policy changes using a difference-in-differences approach that accounts for underlying common secular trends and time invariant differences among countries, and allows for differential effects of the policy by socioeconomic position. Removing user fees was consistent with meaningful increases in facility deliveries across all categories of household wealth and maternal education. We found little evidence of differential effects of removing user fees across quartiles of household wealth, with increases of 5.4 facility deliveries per hundred live births (95% CI: 2.1, 8.8) among women in the poorest quartile and 6.8 per hundred live births (95% CI: 4.0, 9.7) for women in the richest quartile. However, our results suggest that educated women benefited more from removing user fees compared to women with no education. For women with at least some secondary education, the estimated effect was 8.6 facility deliveries per hundred live births (95% CI: 5.4, 11.9), but only 4.6 per hundred live births (95% CI: 2.2, 7.0) for women with no education (heterogeneity p-value = 0.04). Thus, while removing fees at the point of service increased facility deliveries across the socioeconomic gradient, it did not reduce inequalities defined by household wealth and may have contributed to a widening of educational inequalities. These findings emphasize the need for concerted efforts to address financial and other barriers that contribute to large and persistent socioeconomic inequalities in delivery care.

Suggested Citation

  • McKinnon, Britt & Harper, Sam & Kaufman, Jay S., 2015. "Who benefits from removing user fees for facility-based delivery services? Evidence on socioeconomic differences from Ghana, Senegal and Sierra Leone," Social Science & Medicine, Elsevier, vol. 135(C), pages 117-123.
    • Handle: RePEc:eee:socmed:v:135:y:2015:i:c:p:117-123
    DOI: 10.1016/j.socscimed.2015.05.003
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    References listed on IDEAS

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    1. Mats Målqvist & Beibei Yuan & Nadja Trygg & Katarina Selling & Sarah Thomsen, 2013. "Targeted Interventions for Improved Equity in Maternal and Child Health in Low- and Middle-Income Settings: A Systematic Review and Meta-Analysis," PLOS ONE, Public Library of Science, vol. 8(6), pages 1-10, June.
    2. Alexander S. Preker & John C. Langenbrunner, 2005. "Spending Wisely : Buying Health Services for the Poor," World Bank Publications - Books, The World Bank Group, number 7449.
    3. Adam Wagstaff & Mariam Claeson, 2004. "The Millennium Development Goals for Health : Rising to the Challenges," World Bank Publications - Books, The World Bank Group, number 14954.
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    1. Parmar, Divya & Banerjee, Aneesh, 2019. "How do supply- and demand-side interventions influence equity in healthcare utilisation? Evidence from maternal healthcare in Senegal," Social Science & Medicine, Elsevier, vol. 241(C).
    2. Boniface Oyugi & Olena Nizalova & Sally Kendall & Stephen Peckham, 2024. "Does a free maternity policy in Kenya work? Impact and cost–benefit consideration based on demographic health survey data," The European Journal of Health Economics, Springer;Deutsche Gesellschaft für Gesundheitsökonomie (DGGÖ), vol. 25(1), pages 77-89, February.
    3. Mladovsky, Philipa & Ba, Maymouna, 2017. "Removing user fees for health services: A multi-epistemological perspective on access inequities in Senegal," Social Science & Medicine, Elsevier, vol. 188(C), pages 91-99.
    4. Renard, Yohan, 2022. "From fees to free: User fee removal, maternal health care utilization and child health in Zambia," World Development, Elsevier, vol. 156(C).
    5. Beuermann, Diether W. & Pecha, Camilo J., 2020. "The effect of eliminating health user fees on adult health and labor supply in Jamaica," Journal of Health Economics, Elsevier, vol. 73(C).

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