Research Article: Assessing regional variations in the effect of the removal of user fees on facility-based deliveries in rural Zambia

Date Published: December , 2017

Publisher: Makerere Medical School

Author(s): Chama-Chiliba Chitalu, Koch Steven.


Maternal health remains a concern in sub-Saharan Africa, where maternal mortality averages 680 per 100,000 live births and almost 50% of the approximately 350,000 annual maternal deaths occur. Improving access to skilled birth assistance is paramount to reducing this average, and user fee reductions could help.

The aim of this research was to analyse the effect of user fee removal in rural areas of Zambia on the use of health facilities for childbirth. The analysis incorporates supply-side factors, including quantitative measures of service quality in the assessment.

The analysis uses quarterly longitudinal data covering 2003 (q1)-2008 (q4) and controls for unobserved heterogeneity, spatial dependence and quantitative supply-side factors within an Interrupted Time Series design.

User fee removal was found to initially increase aggregate facility-based deliveries. Drug availability, the presence of traditional birth attendants, social factors and cultural factors also influenced facility-based deliveries at the national level.

Although user fees matter, to a degree, service quality is a relatively more important contributor to the promotion of facility-based deliveries. Thus, in the short-term, strengthening and improving community-based interventions could lead to further increases in facility-based deliveries.

Partial Text

Maternal health remains a global challenge in sub-Saharan Africa, where maternal mortality averages 680 per 100,000 live births and almost 50% of the approximately 350,000 annual maternal deaths occur.1–2 There is a need to further facilitate skilled birth assistance and facility-based deliveries (FBDs),2–4 because skilled birth assistance is the single most important factor in preventing maternal deaths.5 Despite its importance, only 20–40% of women in developing countries deliver in a health facility; 6 and approximately 70% of births among poor women take place at home.7

User fees for health services were introduced in many developing countries in the late 1980s, with the aim of financing health care and including maternal health care. Advocates supporting healthcare user fees argue that they enhance the efficient allocation of goods and services by targeting the population in need of the good or service, i.e., low valuation consumers are screened.19 Also, if higher prices are perceived to reflect better quality, user fees could increase demand,20 a potential virtuous cycle, at least in terms of revenue generation. However, the removal of user fees could also have negative effects on equity and access.21–23 In an effort to increase healthcare accessibility, by reducing the direct financial cost associated with treatment, most countries in sub-Saharan Africa abolished or reduced user fees for health services, including maternity services and delivery services,24–27 or exempted certain groups from payment.28–29

There is an extensive literature relating health financing policy changes to health service utilisation.24–26,35,39 Some studies could be biased,40 while only a few have accounted for specific time series properties and problems.24,35 However, in a review of 20 articles, the abolition of user fees has generally been found to have positive effects on the utilisation of health services.41

The abolition of user fees reduces the financial cost of treatment, and is expected to increase utilisation rates. Studies in Zambia and other developing countries have uncovered increases in the use of health services by some population groups, after the removal of user fees,24–26,35 and our results at the national level are consistent with that in literature. Moreover, the findings highlight the importance of quality of services in encouraging FBDs at the national level, but there are important variations at the regional level.

This research investigates the impact of user fee abolition, with specific focus on regional variation, on FBDs using a panel of 9 Zambian provinces covering the period 2003(q1) to 2008(q4). Different models are estimated to address heterogeneity, auto-correlation, hetero-scedasticity and cross-section dependence within a panel data context. After the econometric issues were addressed, the aggregate results provide strong evidence that the abolition of user fees had an immediate positive impact on FBDs. However, the increase was not sustained via an increase in the trend, and the increase was economically small, 1.2 percentage points or 3.4% or pre-intervention births. The aforementioned aggregate increase could not be ascribed to an increase in any particular region. Instead, immediate decreases were uncovered in some regions, while trend increases were uncovered in other regions. In other words, the aggregate results mask interesting regional heterogeneity. From a policy perspective, that heterogeneity is likely to be important; motivations for non-FBDs might be social or cultural, factors not easily altered through reductions in the direct cost of delivery. Similary, although it was not possible to consider indirect charges, as data was not available, anecdotal evidence suggests that facilities have followed a cost-shifting strategy, and that strategy could account for the economically small user fee impacts estimated here, as well as the variation in the effects uncovered.




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