User fees exemptions alone are not enough to increase indigent use of healthcare services

Abstract

The aim of this study was to assess whether user fees exemptions increased healthcare services use among indigents in the Ouargaye district in Burkina Faso. In this pre-post study, we surveyed 1224 indigents in 2010 about their healthcare services use over the preceding 6 months. Of these, 540 subsequently received a user fees exemption card. A follow-up survey was conducted 1 year later with a 55.3% retention rate. Analyses were performed in accordance with Andersen and Newman's model (Societal and individual determinants of medical care utilization in the United States. Milbank Q 1973;51:95-124) to explain healthcare services use by considering predisposing and facilitating factors and health needs indicators. Logistic regression analyses were performed.Among indigents exempted from user fees, 46.2% increased their healthcare services use in 2011, as opposed to 42.1% among the non-exempted. Being exempted was not associated with increased use of services (odds ratio, OR = 1.1, 95% confidence interval, CI [0.80-1.51]). Regardless of whether they were exempted or not, the indigents most likely to have increased their healthcare services use were older than 69 years of age (OR = 1.66, 95% CI [1.05-2.64]), male (OR = 1.44, 95% CI [0.99-2.08]), in low-income households (OR = 1.71, 95% CI [1.15-2.54]), and had received financial support from their families to obtain healthcare (OR = 1.59, 95% CI [1.1-2.28]). The indigents' increased healthcare services use was not attributable to user fees exemptions. Some contamination of the intervention is conceivable. Interventions combining user fees exemptions with actions targeting other obstacles to healthcare access would probably be more effective in increasing indigents' use of healthcare centres.

Maternal health care services utilisation in the context of ‘Abiye’ (safe motherhood) programme in Ondo State, Nigeria

“…This suggests that the 'Abiye' initiative is has not adequately discouraged the utilisation of faith-based services. This is finding is consistent with the fact that scholars agree that user fee exemption policy is effective, but alone is not sufficient to eliminate inequality of access to maternal health care services' utilisation [27,28]. As such, a new approach is required to discourage the use of faithbased services, especially in urban areas among less educated women.…”

Do Targeted User Fee Exemptions Reach the Ultra-Poor and Increase their Healthcare Utilisation? A Panel Study from Burkina Faso

“…Compared with Cambodia’s land area of 181,035 km 2 , Zambia is four times bigger (land area: 752,618 km 2 ), an important characteristic that might have contributed to the differences in the impact of the user fee removal across the countries, since the population (Cambodia: 15 million; Zambia 17 million) is spread over a larger area making access to healthcare services more difficult. Atchessi et al (2014) conducted a pre–post study in Ouargaye (Burkina Faso) and reported an increase in health service utilisation among the ultra-poor from 2010 to 2011, which was, however, not associated with the distribution of exemption cards [ 15 ]. In line with our findings, the study also argues that sociocultural factors such as gender and cultural beliefs, as well as affordable transportation, might have been more influential determinants.…”

“…Information about the ultra-poor’s consumption or income/assets (study population = ultra-poor without financial means) was not available in the dataset. The expected directions of the coefficients ( Table 2 ) were informed by previous evidence on the determinants of healthcare utilisation among rural and vulnerable populations [ 15 , 30 , 31 , 32 ].…”

“…Most evidence originates from other countries such as Cambodia, Cameroon, Morocco and Zambia which generally show an increase in service utilisation among the ultra-poor [ 7 , 8 , 9 , 10 , 11 ] or addresses other population groups [ 12 , 13 , 14 ]. In Burkina Faso, only Atchessi et al (2016) conducted a pre–post study in one district and reported that the distribution of user fee exemption cards did not increase healthcare utilisation [ 15 ]. Reasons for the paucity of evidence include the extremely poor living conditions and the accompanied difficulties in recruiting the ultra-poor for research.…”

Malaria Case Fatality Rate among Children under Five in Burkina Faso: An Assessment of the Spatiotemporal Trends Following the Implementation of Control Programs

“…The negative effects of the "pay and use health services" policy, in use in sub-Saharan African countries, on populations access to healthcare have been consistently documented [6,7]. As a consequence, the debate on the financing of healthcare has shifted from the "pay and use" to the "free of charge" service approach in favor of children under five and pregnant women who are the most vulnerable populations to malaria [8][9][10][11][12][13][14][15][16]. As of 2016, a free healthcare policy (FHC) for children under five and pregnant women was then launched [17].…”