In an effort to address life threatening financial barriers to skilled birth attendance in Burkina Faso, the government launched a national policy in 2006 to subsidise the cost of child delivery. Our research in Ouargaye district found an increase in the use of maternal health services by poor women and a substantial reduction in the cost of deliveries.
The subsidy package introduced in 2006/7 includes: a 60% – 80% subsidy for the direct cost of deliveries (with full exemption for indigent women), as well as a 100% subsidy for the cost of transportation for caesarean referrals. The findings from our research are as follows:
The number of poor women using maternal health services increased: Before 2006/7, user fees meant that women in higher income groups used obstetric care more than poor women. Following the introduction of the subsidy, service utilisation increased substantially across all income groups and especially so for poor women. However, inequity in access to care still exists because relative to their health needs, women from lower income groups have less access to obstetric care. This is partly explained by the facts that, with the exception of the very poorest, women still have to pay at least 20% of the direct costs of delivery. Poor women also face significant geographical barriers with services being much easier to reach by those in higher income groups. Removing these remaining barriers (i.e. geographic and financial) will make access to obstetric care more equitable.
Substantial reduction in the cost of deliveries for poor women: The average medical cost of deliveries reduced significantly by 65% after the introduction of the subsidy. Also, average total expenses for deliveries went down from $18 in 2006 to $11.6 in 2010. Women in the poorest income bracket benefited most from the reduction. The distribution of benefits from the subsidy was progressive in the sense that it resulted in a decrease in medical expenses for women in the lower income group (-14%) and an increase in the cost of care for those in the upper income bracket (+15%). However, there were still a significant number of women (about half of all the women interviewed) who were paying more for normal delivery than the official cost of $1.80. The main cause for this was the purchase of medical products and medicine.
Risk of catastrophic medical expenditure significantly reduced: The proportion of households at risk of obstetric care-related excessive medical expenditure reduced considerably for all women – down from 6–12 % in 2006 to 1-2.5% in 2010. The reduction in risk of catastrophic expenditure was felt more by poor women living near a medical centre (demonstrating the importance of geographical barriers). Overall, only a small portion of the population was found still to be subjected to excessive medical expenses after the introduction of the policy.
The number of women receiving 100% exemption increased though about half of all eligible indigent women could still not benefit from it. The distribution of the benefits was progressive because the majority of the beneficiaries were poor women. The relative success of the exemption policy is partly due to an action research project that was carried out in the Ouargaye district which faciliated the indentification of eligible indigent women. However, the fact that many eligible indigent women are still not beneffiting from the exemption suggests that such targeting is still problematic.
Despite the success of the subsidy policy, poor women in Burkina Faso still face significant financial barriers in accessing obstetric care. While many indigent women are eligible for 100% exemption, many still cannot access it; most women have to pay at least 20% of the direct cost of delivery services; and all (with the exception of those referred for caesareans) have to bear the indirect cost of transportation.
To make the child delivery subsidy policy more effective and equitable, the government needs to remove the remaining financial barriers by making obstetric care free for all women at the point of use as promised by the President of the Republic in early 2010. The government should also consider alleviating non-medical costs related to obstetric care for poor women, including transportation, so that everyone can benefit equally from the healthcare subsidy policy.
Policy makers from other countries can learn from the Burkina Faso example. Removing user fees for health care (or subsidisation) is an effective strategy for reducing inequalities in access to healthcare and alleviating catastrophic health expenditure. User fees removal should be seen as a positive step forward that needs to be matched with efforts to strengthen and improve the quality of the healthcare delivery system. Countries that continue with user fees need to recognise the enormous barrier to access such fees present and that efforts to remove fees and improve the healthcare delivery system can work to enhance the health of their population, avoid unnecessary death, and avert household poverty.
Valéry Ridde, Ph.D., is a professor of public health at the University of Montreal, a researcher at the CRCHUM, a CIHR New Investigator, and Associate Research at the IRSS/CNRST Burkina Faso. To read further on Valéry’s other publications, visit: http://www.pum.umontreal.ca/ca/fiches/978-2-7606-2278-4.html
This blog is drawn from the research programme “L’abolition du paiement des services de santé en Afrique de l’Ouest” (“The abolition of user fees for health services in West Africa” financed by IDRC/AFD). For further information on the project visit http://www.lasdel.net/gratuit%E9.htm or http://www.vesa-tc.umontreal.ca/ressrc.htm