User fee exemptions and equity in access to caesarean sections: an analysis of patient survey data in Mali

International Journal for Equity in Health

Timothee Gandaho²  Laurel Hatt¹  Marianne El-Khoury³ 

[1] Senior Associate/Health Economist, Abt Associates Inc, 4550 Montgomery Ave, Suite 800 North, Bethesda, MD 20814, USA;Senior Advisor & Team Leader, Abt Associates, Bamako, MALI;Associate/Economist, Abt Associates Inc, 4550 Montgomery Ave, Suite 800 North, Bethesda, MD 20814, USA

关键词: Access;    Mali;    Caesarean sections;    Equity;    User fees;   

Others  :  828306
DOI  :  10.1186/1475-9276-11-49

 received in 2012-03-20, accepted in 2012-08-06,  发布年份 2012

【 摘 要 】

Introduction

Little rigorous evidence exists on how health service utilization varies across socioeconomic groups after a user fee exemption policy has been implemented, and the evidence that does exist is mixed. In this paper, we estimate the distribution of caesarean section deliveries across socioeconomic groups following Mali’s implementation of a fee exemption policy for caesareans in 2005.

Methods

We conducted a patient survey in 2010 to collect socioeconomic data from 2,477 women who had caesareans in a representative sample of 25 facilities across all regions of Mali. We used these data along with data from the most recent Demographic and Health Survey to construct a wealth index and classify women into population-based wealth groupings. We compared the wealth distribution of women delivering via caesarean section to that of a nationally representative sample of women giving birth.

Results

We found that wealthier women make up a disproportionate share of those having free caesareans, five years after implementation of the fee exemption policy. Women in the richest two quintiles accounted for 58 percent of all caesareans, while women in the poorest two quintiles accounted for 27 percent of all caesareans. Fewer women in the poorest two-fifths of the population are receiving caesareans than what we would expect given their share in the population of women giving birth.

Conclusions

While fee exemptions remove important financial barriers to accessing priority maternal health services, they are insufficient to ensure equal access among wealth groups.

【 授权许可】

   
2012 El-Khoury et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]James C, Hanson K, McPake B, Balabanova D, Gwatkin D, Hopwood I, Kirunga C, Knippenberg R, Meessen B, Morris S, Preker A, Souteyrand Y, Tibouti A, Villeneuve P, Xu K: To retain or remove user fees? Reflections on the current debate in low-and middle-income countries. London School of Hygiene and Tropical Medicine. Appl Health Econ Health Policy 2006, 5(3):137-153.
• [2]Lagarde M, Palmer N: The impact of user fees on access to health services in low-and middle-income countries. Bull World Health Organ 2008, 86(11):839-848.
• [3]Nabyonga J, Desmet M, Karamagi H, Kadama PY, Omaswa FG, Walker O: Abolition of cost-sharing is pro-poor: evidence from Uganda. Health Policy Plan 2005, 20(2):100-108.
• [4]Ridde V, Diarra A: A process evaluation of user fees abolition for pregnant women and children under five years in two districts in Niger (West Africa). BMC Health Serv Res 2009, 9:89. BioMed Central Full Text
• [5]Abdu Z, Mohammed Z, Bashier I, Eriksson B: The impact of user fee exemption on service utilization and treatment seeking behavior: the case of malaria in Sudan. Int J Health Plann Manage 2004, 19(Suppl 1):S95-S106.
• [6]Uzochukwu B, Onwujekwe O, Eriksson B: Inequity in the Bamako initiative programme: implications for the treatment of malaria in south-east Nigeria. Int J Health Plann Manage 2004, 19(Suppl 1):S107-S116.
• [7]Pitchforth E, van Teijlingen E, Graham W, Fitzmaurice A: Development of a proxy wealth index for women utilizing emergency obstetric care in Bangladesh. Health Policy Plan 2007, 22:311-319.
• [8]Cellule de Planification et de Statistique du Ministère de la Santé (CPS/MS), Direction Nationale de la Statistique et de l’Informatique, Ministère de l’Économie, de l’Industrie et du Commerce, Macro International Inc: Enquête Démographique et de Santé du Mali 2006 (EDSM-IV). Enquête Démographique et de Santé du Mali 2006 (EDSM-IV), Calverton, MD: CPS/DNSI and Macro International Inc; 2006.
• [9]Paxton A, Maine D, Freedman L, Fry D, Lobis S: The evidence for emergency obstetric care. Int J Gynecol Obstet 2005, 88:181-193.
• [10]Campbell OM, Graham WJ: Strategies for reducing maternal mortality: getting on with what works. Lancet 2006, 368:1284-1299.
• [11]World Health Organization: Indicators to monitor maternal health goals. In Report of a Technical Working Group. WHO, Geneva; 1994.
• [12]Diaby M: Etude de la Césarienne à la Maternité du Centre de Santé de Référence de la Commune I du District de Bamako. In Thesis. Faculté de Médecine, de Pharmacie, et d’Odontostomatologie, Université de Bamako; 2006.
• [13]Diallo O: La Césarienne Aspects Épidémiologiques, Cliniques, Socio-économiques et Pronostic Materno-Foetal à L'Hôpital Régional de Gao. In Thesis. Faculté de Médecine, de Pharmacie, et d’Odontostomatologie, Université de Bamako; 2006.
• [14]Diarra MG: Etude de la Césarienne à la Maternité de l’Hôpital Nianankoro Fomba de Ségou. In Thesis. Faculté de Médecine, de Pharmacie, et d’Odontostomatologie, Université de Bamako; 2006.
• [15]Guirro B: Etude de la Césarienne dans le Service de Gynéco Obstétrique de L’Hôpital Régional Sominé Dolo de Mopti. In Thesis. Faculté de Médecine, de Pharmacie, et d’Odontostomatologie, Université de Bamako; 2006.
• [16]Abt Associates Inc, Health Systems 20/20 project: Improving access to life-saving maternal health services: the effects of removing user fees for caesareans in Mali. Abt Associates Inc, Bethesda, MD; 2011.
• [17]Ridde V, Morestin F: A scoping review of the literature on the abolition of user fees in health care services in Africa. Health Policy Plan 2010, 26:1-11.
• [18]Measure DHS-Mali: Standard DHS, 2006 Dataset. http://www.measuredhs.com/data/dataset/Mali_Standard-DHS_2006.cfm webcite
• [19]Rutstein SO, Johnson K: The DHS wealth index. In DHS Comparative Reports No. 6. ORC Macro, Calverton, MD; 2004.
• [20]Filmer D, Pritchett LH: Estimating wealth effect without expenditure data – or tears: an application to educational enrollments in states of India. Demography 2001, 38:115-132.