The long-term effects of free care on birth outcomes: Evidence from a national policy reform in Zambia

Abstract

As women in many countries still fail to give birth in facilities due to financial barriers, many see the abolition of user fees as a key step on the path towards universal coverage. We exploited the staggered removal of user charges in Zambia from 2006 to estimate the effect of user fee removal up to five years after the policy change. We used data from the birth histories of two nationally representative Demographic and Health Surveys to implement a difference-in-differences analysis and identify the causal impact of removing user charges on institutional and assisted deliveries, caesarean sections and neonatal deaths. We also explored heterogeneous effects of the policy. Removing fees had little effect in the short term but large positive effects appeared about two years after the policy change. Institutional deliveries in treated areas increased by 10 and 15 percentage points in peri-urban and rural districts respectively (corresponding to a 25 and 35 percent change), driven entirely by a reduction in home births. However, there was no evidence that the reform changed the behaviours of women with lower education, the proportion of caesarean sections or reduced neonatal mortality. Institutional deliveries increased where care quality was high, but not where it was low. While abolishing user charges may reduce financial hardship from healthcare payments, it does not necessarily improve equitable access to care or health outcomes. Shifting away from user fees is a necessary but insufficient step towards universal health coverage, and concurrent reforms are needed to target vulnerable populations and improve quality of care.

Keywords: Care-seeking; Maternal care; Neonatal mortality; User fees; Zambia.

Fig. 1

Effect of user fees removal on delivery outcomes and neonatal mortality over time. Note: The effect of the policy is represented for each year, with its confidence intervals. Each effect is estimated by using district and year fixed effects. Standard errors are clustered at the mother level, sampling weights included. Note that in Fig. 2B, the effect for 2007 is not presented given that only 10 children were born after June in a peri-urban areas. Outcomes are defined in the same was as those presented in Table 2.

Fig. 2

Heterogeneous effects of user fee removal on the proportion of institutional and assisted deliveries. Note: Triple-difference models were used to test whether the outcomes across sub-group were statistically different. For the policy change in rural areas (top), the differences observed across extreme quintiles in wealth and quality of services are not statistically significant, but mothers with low education were significantly less likely to deliver in a facility (p = 0.027) or be assisted in their delivery (p = 0.032). For the policy change in peri-urban areas (bottom), the differences observed across education levels and quality of services are not statistically significant, but mothers from the wealthiest quintiles were significantly less likely to deliver in a facility (p = 0.001) or be assisted in their delivery (p = 0.003).