Immediate and sustained effects of user fee exemption on healthcare utilization among children under five in Burkina Faso: A controlled interrupted time-series analysis
Introduction
Population-based studies suggest that improved access to health care has the potential to produce a significant reduction in under-five morbidity in developing countries (Rutherford et al., 2010), but this improvement can only occur when children actively (Yates, 2009) and promptly use health facilities. A wide range of factors affect access to health care in low-middle income countries (LMICs), with user fee identified as one of the greatest obstacles (Ridde, 2015). In Burkina Faso, over half of the population lives on less than 1 US dollar per day with a national average of 54–56% of children under five reported to use health services when ill (INSD & Macro, 2012), compared to 32% in the most deprived areas of the country (Ridde, Haddad and Heinmuller, 2013). Inequalities in morbidity and use of services according to socioeconomic status and place of residence persist across the country (INSD & Macro, 2012).
In an effort by the World Health Organization and the African Union to achieve the provision of universal coverage of primary health care (Yates, 2009), many African countries are attempting to remove financial obstacles to health services access (Ridde, 2015). The government of Burkina Faso has experimented with user fee exemption for women and children under-five since September 2008 (Ridde et al., 2013a, Ridde et al., 2013b). This pilot intervention was delivered within the context of a population health intervention research study; whereby complete user fee exemption was implemented in two out of four districts in the Sahel region.
Studies across several low-income countries have shown that, globally, user fee exemption is typically associated with an immediate increase in the use of maternal and child health care services (Bassani et al., 2013, Lagarde and Palmer, 2011; Ridde and Morestin, 2011). Most studies have analyzed the effect of free care policies on maternal outcomes such as assisted deliveries and caesarian sections. In particular, McKinnon et al. (2014) showed that user fee exemption was consistent with an increase of 3.1 facility-based deliveries per 100 live births and an estimated reduction of 2.9 neonatal deaths per 1000 births (McKinnon et al., 2014). In Ghana, following user fee exemption policies from 2005 to 2008 and a policy exempting pregnant women from paying the national Health insurance registration and premium fees, facility deliveries increased significantly over time (Dzakpasu et al., 2012). In Addition, Fournier et al. (2014) showed that the implementation of a free caesarian section policy increased the rate of caesarian section deliveries from 1.7 to 5.7% for Malian women living in cities without any significant change in trends among women living in villages (Fournier et al., 2014). With regard to children under five more specifically, free care was associated with an immediate increase of service use among children under five in Mali, with user attendance multiplied by 1.5 during the rainy season (Heinmüller et al., 2013). The effect was maintained in all facilities up to three years after the intervention onset (Heinmüller et al., 2013). In the case of Burkina Faso, two studies that have analyzed the effect of user fee exemption policy reported an increase in the use of health services among children under five (Druetz et al., 2015; Ridde et al., 2013a, Ridde et al., 2013b).
Given that most evaluations were conducted early, within three years after the policy change (Hatt et al., 2014, Lagarde and Palmer, 2011), the important research question regarding the long-term effect of this intervention on access to health services and on health outcomes among children under five remains relatively unexplored (Bassani et al., 2013). Indeed, the lack of appropriate data and weaknesses of research designs have led most studies to be limited to the analysis of linear short-term effects (Ridde and Morestin, 2011, Yates, 2009) and few have accounted for long-term trends and confounding factors (Dzakpasu et al., 2013, Lagarde and Palmer, 2008) or effect modifiers, which mainly include factors related to characteristics of health facilities and their environment that may interact with and alter the effect of the intervention (Hatt et al., 2014, Victora et al., 2005). In the context of Africa and particularly in Burkina Faso, the need for strong evidence supporting the scaling up of pilot exemption policies through the formulation of public policies is urgent (Ridde, 2015), especially considering the Government of Burkina Faso has decided to implement a nationwide exemption policy starting April 2016.
This study examines the strength of effect and long term effects of user fee exemption policy on the rate of health service utilization by children under five years of age in rural health facilities in Burkina Faso. In addition, it explores whether contextual and health service factors moderate the association between user fee exemption and health service utilization for children under five.
Section snippets
Study settings
The study was conducted in the northern region of Burkina Faso, where two out of four rural districts (Fig. 1) began to implement user fee exemption in 2008. The region has 1,160,000 inhabitants, mostly consisting of herders and farmers, with similar demographics among the districts (Ridde et al., 2013a, Ridde et al., 2013b). Starting in September 2008, regional health authorities from districts of Dori (313,497 inhabitants, 23 primary health care facilities (PHC)) and Sebba (191,810
Statistical analysis
We plotted all the variables over time to allow for the visual identification of trend and seasonality as well as outliers and the functional forms of variables. We used two-level mixed-effects negative binomial modeling to account not only for overdispersion but also for the hierarchical structure of data, i.e. the repeated measure of monthly utilization rate (level 1) within the single facility (level 2).
We tested linear, linear spline, logarithmic and quadratic functional form for the
Ethics approval
The research was accepted by the Ministry of Health and ethics committees in Burkina Faso and Canada (CRCHUM).
Descriptive statistics and trends
Table 1 presents descriptive statistics related to the crude rate of health service utilization among children under five before and after the implementation of the intervention in comparison and intervention facilities. We included 40 comparison health centers and 28 intervention health centers.
As shown in Fig. 2, which presents the monthly average rates per group over time, there was an almost linear and relatively stable trend in the use of health services by children under five in both
Discussion
This is the first study to use a controlled interrupted time-series design to assess the long-term effects of user fee exemption policy on health service utilization for children under five. The results show a substantial and immediate increase in the rate of service utilization in intervention facilities during the month following the implementation of the intervention. Our findings also indicate that, although the intervention effect was substantially significant immediately in the first
Conclusion
Our results provide additional evidence to support the view that user fee exemption coupled with improvements in quality of care can result in both an immediate and a sustained increase in service utilization for children under five. While the intervention effect was higher in facilities with higher health worker density, reducing inequalities in health worker allocation and improving health workforce capabilities and public financing are needed to maintain a long-term intervention impact. Our
Funding
VR holds a Canadian Institutes of Health Research (CIHR)-funded Research Chair in Applied Public Health (CPP-137901). DZ received funding from International Development Research Center (IDRC) of Canada for data collection, He is also supported by the Quebec Health Research Fund (FRQS). The funders and the NGO had no role in study design, data collection and analysis.
Competing interests
We declare that we have no competing interests.
Authors' contributions
VR and DZ designed the study. DZ acquire data, led the analyses and drafted the manuscript in consultation with other authors. All authors interpreted the results, reviewed the article. VR and MA critically reviewed improved and approved the final version of the manuscript.
Acknowledgments
The authors thank the managers and the staff of the intervention studied (HELP), the health district authorities in Dori, Gorom-Gorom, Djibo and Sebba, as well as the health workers for their collaboration in this study. Thanks to Kate Zinszer and Tarik Benmarhnia for critically revising the manuscript and also to Danielle Wilhelm for editing the final manuscript.
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2020, Value in HealthCitation Excerpt :First, one must consider our estimates as the cost-effectiveness of user-fee removal and reduction combined with quality improvement. Because the national policy was implemented in a functioning health system with possibly concurrent activities targeting quality of care29 and the pilot was implemented with accompanying quality improvement measures,30 we had no way of disaggregating the impact of user-fee reduction and removal from quality improvements. Nevertheless, we have thoroughly assessed the impact of quality changes on our model results, and our core findings remained consistent.