Removing user fees for facility-based delivery services: a difference-in-differences evaluation from ten sub-Saharan African countries

Abstract

Background: 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 on utilization of delivery services and no evaluations have examined effects on neonatal mortality rates (NMR). In this article, we estimate the causal effect of removing user fees on the proportion of births delivered in facilities, the proportion of births delivered by Caesarean section, and NMR.

Methods: We used data from Demographic and Health Surveys conducted in 10 African countries between 1997 and 2012. Kenya, Ghana and Senegal adopted policies removing user fees for facility-based deliveries between 2003 and 2007, while seven other countries not changing user fee policies were used as controls. We used a difference-in-differences (DD) regression approach to control for secular trends in the outcomes that are common across countries and for time invariant differences between countries.

Results: According to covariate-adjusted DD models, the policy change was consistent with an increase of 3.1 facility-based deliveries per 100 live births (95% confidence interval (CI): 0.9, 5.2) and an estimated reduction of 2.9 neonatal deaths per 1000 births (95% CI: -6.8, 1.0). In relative terms, this corresponds to a 5% increase in facility deliveries and a 9% reduction in NMR. There was no evidence of an increase in Caesarean deliveries. We examined lead and lag-time effects, finding evidence that facility deliveries continued to increase following fee removal.

Conclusions: Our findings suggest removing user fees increased facility-based deliveries and possibly contributed to a reduction in NMR. Evidence from this evaluation may be useful to governments weighing the potential benefits of removing user fees.

Keywords: User fee removal; difference-in-differences; maternal health care; neonatal mortality.

Figure 1

Dates of delivery fee exemption policies and birth history data availability by country. Birth history data for all live births in the 5 years preceding each survey comes from Demographic and Health Surveys conducted between 1997 and 2012. Policies in Ghana and Senegal were passed first in selected regions or provinces and subsequently rolled out to the rest of the country.

Figure 2.

Lead-time and lag effects for facility-based deliveries and NMR. Point estimates represent effects of the delivery fee exemption policy change, estimated at the time of the policy adoption (t = 0) and for the three years before and one year after the policy change. Vertical bars represent 95% CIs for the estimates.