Academic journal article Journal of Health Population and Nutrition

Effects of User Fee Exemptions on the Provision and Use of Maternal Health Services: A Review of Literature

Academic journal article Journal of Health Population and Nutrition

Effects of User Fee Exemptions on the Provision and Use of Maternal Health Services: A Review of Literature

Article excerpt


At the current average rate of change in maternal mortality ratios and neonatal mortality rates, only 31 developing countries will meet Millennium Development Goal 4 (MDG 4)-reducing child deaths-and still fewer (19 countries) will achieve MDG 5-reducing maternal deaths (1). With this slow rate of decline in mind, there have been calls for stakeholders across the globe to explore innovative approaches to achieving these goals, including the use of financial incentives aimed at both consumers and healthcare providers. User fee exemptions-targeted exemptions from out-of-pocket fees charged at some public-sector health facilities-are financial incentives that have both demand-side and supply-side effects; these influence the likelihood that consumers use health services as well as the volume and quality of services offered by providers. This paper reviews evidence on and the effectiveness of such fee policies in contributing to improved maternal and neonatal health.

User fees are often levied by governments to supplement their budget transfers to healthcare facilities in the context of under-funded health systems. Most often, fee revenue is kept at the health facility level and covers local operating costs, including purchase of drugs, supplies, and salary supplements, although, in some contexts, governments may require that this revenue be transferred to the national treasury. Many sub-Saharan African countries instituted user fee policies in the early 1990s after the Bamako Initiative which called for community financing to augment resources available for primary care (especially drug supplies) and to improve quality and increase community involvement (2). Some early studies indicated that using user fee revenue to improve the quality of healthcare could increase demand for government health services (3).

The bulk of evidence has shown that user fees constitute an impediment to health service utilization among the poor (4-6), including facility-based delivery and emergency obstetric care. Fees also divert those who cannot pay to other (informal or private) sources of healthcare (7). To reduce the financial burden on patients and to increase access to healthcare services, many countries have again begun to reduce or eliminate user fees for certain services (fee exemptions), abolish fees for certain groups, such as pregnant women or under-five children (fee waivers), or abolish user fees entirely at primary healthcare facilities. These fee reductions have been put forward as an approach to increasing maternal health service utilization, reducing impoverishment, and ultimately reducing maternal and neonatal mortality.

While there have been several reviews of evidence on the effects of user fees and fee exemptions published in the past decades (8-10), including a recent Cochrane review by Lagarde and Palmer (11) and a special supplement to Health Policy and Planning focused entirely on user fee removal in November 2011, systematic reviews focusing on maternal and neonatal health specifically including both supply- and demand-side effects, have not been published. In 2012, the US Agency for International Development (USAID) commissioned a panel of economists and specialists in maternal and newborn health to conduct a literature review on the effects of user fee exemptions on maternal and newborn health outcomes, healthcare-seeking behaviours, and service provision, including both supply-side and demand-side effects. This paper summarizes the evidence review and addresses the following two focal questions:

* To what extent are user fee exemptions linked positively or negatively to maternal and neonatal health outcomes, the provision of maternal health services, or care-seeking behaviour by women?

* What contextual factors impact the effectiveness of user fee exemption programmes in improving maternal and neonatal health outcomes or the provision or use of maternal health services? …

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