Assessing the community-level impact of a decade of user fee policy shifts on health facility deliveries in Kenya, 2003-2014

Abstract

BackgroundThe long-term impact of user fee removal policies on health service utilization in low- and middle-income countries may vary depending on the context in which they are implemented, including whether there are policy actions to support implementation. We examined the community-level impact of a decade of user fee policy shifts on health facility delivery among poorest and rural women and compared the changes with those among the richest and urban women in Kenya using data from three rounds of nationally representative surveys.MethodsData are from births occurring in the 5 years preceding the survey to women aged 15-49 years who were interviewed in the 2003, 2008-2009 and 2014 Kenya Demographic and Health Surveys. A total of 5949, 6079 and 20,964 births were reported in respective surveys. We conducted interrupted time series analysis predicting changes in quarterly proportions of births occurring in public and private health facilities as well as at home before and after the 2004, 2007 and 2013 user fee policy shifts in Kenya.ResultsThere were no statistically significant immediate changes in the proportion of births occurring in public facilities following the 2004, 2007 and 2013 user fee policy shifts among poor or rural women. There was, however, a statistically significant increase in home deliveries among all women and among those from the poorest households immediately following the 2004 policy. There was also a statistically significant increase in public facility deliveries among women from the two top quintiles, which was accompanied by a statistically decline in home deliveries immediately after the 2007 policy shift. Differences in trends in public facility deliveries between pre- and post-policy periods were not statistically significant for all sub-groups of women, indicating that even among the sub-group that experienced significant immediate increase after the 2007 policy shift, this pattern was not sustained over time.ConclusionThe findings of this paper provide empirical evidence that poorly implemented user fee removal policies benefit more well-off than poor women and in cases where there are significant immediate effects on uptake of facility delivery, this trend is not sustained over time.Electronic supplementary materialThe online version of this article (10.1186/s12939-018-0774-4) contains supplementary material, which is available to authorized users.

Impact of a free care policy on the utilisation of health services during an Ebola outbreak in the Democratic Republic of Congo: an interrupted time-series analysis

“…However, studies have shown mixed evidence with regards to their effectiveness in various contexts. [15][16][17][18] Weak study designs, many of which lacked an adequate control group, may partially explain the mixed evidence. 16 18 An evaluation of a previous FCP introduced in the Democratic Republic of Congo (DRC) in 2008, unrelated to an EVD outbreak, also demonstrated mixed results and the programme was not sustained.…”

Examining user fee reductions in public primary healthcare facilities in Kenya, 1997–2012: effects on the use and content of antenatal care

“…The findings suggest that there were important differences and similarities between the impact of the 10/20 policy on coverage of antenatal care versus delivery care. In a recent paper using Kenya DHS data to examine the impact of the 2004 10/20 policy on coverage and source of delivery care, Obare et al found that the proportion of women who delivered outside of a health facility immediately increased at the population level and among poor women (defined as the bottom two wealth quintiles), but had no immediate effect on home-based delivery care among wealthy women (defined as the top two wealth quintiles) [26]. Further, the study found no immediate effect of the 2004 10/20 policy on use of public facility-based delivery care; instead, the observed reduction in facility-based care was due to decreased use of private facilities and increased home-based births among the poor [26].…”

“…In a recent paper using Kenya DHS data to examine the impact of the 2004 10/20 policy on coverage and source of delivery care, Obare et al found that the proportion of women who delivered outside of a health facility immediately increased at the population level and among poor women (defined as the bottom two wealth quintiles), but had no immediate effect on home-based delivery care among wealthy women (defined as the top two wealth quintiles) [26]. Further, the study found no immediate effect of the 2004 10/20 policy on use of public facility-based delivery care; instead, the observed reduction in facility-based care was due to decreased use of private facilities and increased home-based births among the poor [26]. While Obare and colleagues' findings suggest that the 2004 10/ 20 policy change was associated with decreased coverage of institutional deliveries, particularly among the poor, our findings suggest that the policy change was associated with increased coverage of 4+ ANC, particularly among the better-off.…”

“…The rate of increase in patient numbers eventually declined, but the patient volumes remained higher than those seen before the policy [21,22]. A more recent study of the long-term population-level effects of the 10/ 20 policy on women's source of childbirth care by Obare and colleagues found that the 2004 policy did not increase the proportion of women delivering in public sector facilities or the change in public facility deliveries over time; instead the policy was associated with an immediate increase in the proportion of poor women who delivered outside of a health facility [26]. Further, the study found that after the removal of 10/20 registration fees for childbirth care in public health centers and dispensaries in 2007, there was an immediate increase in the use of public facility-based childbirth care and decrease in non-facility births among the wealthiest women, but no change in childbirth service-seeking among the poorest women.…”

Pro-equity legislation, health policy and utilisation of sexual and reproductive health services by vulnerable populations in sub-Saharan Africa: a systematic review

“…Among included studies, national legislation or policy adoption promoting the access to and utilisation of SRH services spanned the period from 1996 to 2013, with a concentration of studies conducted between 2000 and 2009 (Supplemental Figure 4). Most studies analysed SRH service utilisation from one to eight years before and one to eight years after legislation/policy adoption (23,25,27,30,31,33,38,(42)(43)(44)(45)(46)(47)(48) and between 1 and 14 years after legislation/policy adoption (26,28,29,32,34,37,40,41,(49)(50)(51)(52)(53)(54). Two studies examined service utilisation two to four years before legislation/ policy adoption at time point 1 and the same year at time point 2 (24,39).…”