The effect of user fee exemption on the utilization of maternal health care at mission health facilities in Malawi

Abstract

The Government of Malawi has signed contracts called service level agreements (SLAs) with mission health facilities in order to exempt their catchment populations from paying user fees. Government in turn reimburses the facilities for the services that they provide. SLAs started in 2006 with 28 out of 165 mission health facilities and increased to 74 in 2015. Most SLAs cover only maternal, neonatal and in some cases child health services due to limited resources. This study evaluated the effect of user fee exemption on the utilization of maternal health services. The difference-in-differences approach was combined with propensity score matching to evaluate the causal effect of user fee exemption. The gradual uptake of the policy provided a natural experiment with treated and control health facilities. A second control group, patients seeking non-maternal health care at CHAM health facilities with SLAs, was used to check the robustness of the results obtained using the primary control group. Health facility level panel data for 142 mission health facilities from 2003 to 2010 were used. User fee exemption led to a 15% (P < 0.01) increase in the mean proportion of women who made at least one antenatal care (ANC) visit during pregnancy, a 12% (P < 0.05) increase in average ANC visits and an 11% (P < 0.05) increase in the mean proportion of pregnant women who delivered at the facilities. No effects were found for the proportion of pregnant women who made the first ANC visit in the first trimester and the proportion of women who made postpartum care visits. We conclude that user fee exemption is an important policy for increasing maternal health care utilization. For certain maternal services, however, other determinants may be more important.

Removal of user fees and system strengthening improves access to maternity care, reducing neonatal mortality in a district hospital in Lesotho

“…This lack of evidence results from both the number and quality of existing studies [23]. Despite this, there is consistency in the direction of effect, particularly when assessing the impact of fees on facility (primary health care-and hospital-level) deliveries [3][4][5][6][7][8][9][10][11][12]. Our findings are consistent with this trend and importantly are able to assess not only access to care but also delivery outcomes and the presentation of complications during delivery.…”

“…Maternal deaths can be greatly reduced by increasing the number of births attended by a skilled birth attendant, alongside timely access to secondary and tertiary care. There is a growing body of evidence to suggest removal or minimisation of fees for antenatal and delivery services improves maternal and neonatal outcomes and increases facilitybased deliveries [3][4][5][6][7][8][9][10][11][12]. Lesotho could improve its maternal mortalityamong the highest globallyby removing user fees for hospital delivery care.…”

User fee exemption and maternal health care utilisation at mission health facilities in Malawi: An application of disequilibrium theory of demand and supply

“…The exceptions are Burundi and Afghanistan where no statistically significant effects were found (Nimpagaritse & Bertone, ; Steinhardt et al, ). User fee exemption has been associated with a 34% increase in postnatal care visits in Uganda (Deininger & Mpuga, ), and no effect was found in Malawi (Manthalu, Yi, Farrar, & Nkhoma, ).…”

“…In Uganda, user fee abolition was associated with a 12% increase in utilisation of ANC and in Sierra Leone, a 35% increase (Deininger & Mpuga, 2005;UNICEF, 2011). In Malawi, the mean proportion of women who made at least one ANC visit during pregnancy increased by 15%, and the average ANC visits increased by 12% (Manthalu, Yi, Farrar, & Nkhoma, 2016).…”

Conditional Cash Transfers Improve Retention in PMTCT Services by Mitigating the Negative Effect of Not Having Money to Come to the Clinic

“…In fact, in most countries in sub-Sahara Africa, hospitals and clinics are funded on a fee-per-service basis, and HIV-infected women have to be able to pay for their antenatal visits registration and delivery costs, as well as register for the well-baby clinic visit in the postpartum period to be able to continue to have access to the clinic at each of those steps. 19 The magnitude and structure of those fees varies by clinic and might explain why some women switch clinics during and after pregnancy. 9 …”