Effects of User Fee Exemptions on the Provision and Use of Maternal Health Services: A Review of Literature

User fee removal has been put forward as an approach to increasing priority health service utilization, reducing impoverishment, and ultimately reducing maternal and neonatal mortality. However, user fees are a source of facility revenue in many low-income countries, often used for purchasing drugs and supplies and paying incentives to health workers. This paper reviews evidence on the effects of user fee exemptions on maternal health service utilization, service provision, and outcomes, including both supply-side and demand-side effects. We reviewed 19 peer-reviewed research articles addressing user fee exemptions and maternal health services or outcomes published since 1990. Studies were identified through a USAIDcommissioned call for evidence, key word search, and screening process. Teams of reviewers assigned criteria- based quality scores to each paper and prepared structured narrative reviews. The grade of the evidence was found to be relatively weak, mainly from short-term, non-controlled studies. The introduction of user fee exemptions appears to have resulted in increased rates of facility-based deliveries and caesarean sections in some contexts. Impacts on maternal and neonatal mortality have not been conclusively demonstrated; exemptions for delivery care may contribute to modest reductions in institutional maternal mortality but the evidence is very weak. User fee exemptions were found to have negative, neutral, or inconclusive effects on availability of inputs, provider motivation, and quality of services. The extent to which user fee revenue lost by facilities is replaced can directly affect service provision and may have unintended consequences for provider motivation. Few studies have looked at the equity effects of fee removal, despite clear evidence that fees disproportionately burden the poor. This review highlights potential and documented benefits (increased use of maternity services) as well as risks (decreased provider motivation and quality) of user fee exemption policies for maternal health services. Governments should link user fee exemption policies with the replacement of lost revenue for facilities as well as broader health system improvements, including facility upgrades, ensured supply of needed inputs, and improved human resources for health. Removing user fees may increase uptake but will not reduce mortality proportionally if the quality of facility-based care is poor. More rigorous evaluations of both demand- and supply-side effects of mature fee exemption programmes are needed

A Benefit-Cost Analysis of Measles Vaccinations in Yaounde, Cameroon

This paper discusses the issues involved in application of benefit-cost analysis to health programs and suggests some new approaches to them. The method developed is applied to the case of measles vaccinations given in Yaounde, Cameroon in 1971-1976. the results show that high benefit-cost ratios are obtained under the most conservative assumptions. further, it is shown that giving more vaccination could have earned an even greater return. A Reed-Frost epidemiological model is used to find spillover benefits to vaccinations. A herd immunity level of 59 percent of the 6-26 months population is found.Center for Research on Economic Development, University of Michiganhttp://deepblue.lib.umich.edu/bitstream/2027.42/100875/1/ECON328.pd

A Model of Meat Versus Live-Animal Exports from Upper Volta

This paper develops a theoretical model of livestock and meat exports from Upper Volta. The model is depicted graphically, showing the existence of jointly-determined unique equilibrium levels of live-animal and meat exports given costs and relevant demands for meat and offals. The model shows how conditions leading to a greater proportion of meat to live-animal exports are self-braking because of the interrelationship of domestic and export markets and explains the observation of declining meat exports in periods of rising prices. The cause of this phenomenon is shown to be the price of non-tradable by-products of cattle slaughtered in Upper Volta for export as meat. The paper examines the impact of a series of exogenous effects on meat exports. The most important policy conclusion is that exogenous changes favoring either mode of export tend to be restricted in their effect by the self-braking nature of the system. The greatest likelihood for promoting increased meat exports from Upper Volta appears to be increasing the capacity to process and export offals and decreasing the transportation costs of meat relative to live animals.Center for Research on Economic Development, University of Michiganhttp://deepblue.lib.umich.edu/bitstream/2027.42/100877/1/ECON329.pd

Effects of mutual health organizations on use of priority health-care services in urban and rural Mali: a case-control study

OBJECTIVE: To examine the effects of a community-based mutual health organization (MHO) on utilization of priority health services, financial protection of its members and inclusion of the poor and other target groups. METHODS: Four MHOs were established in two districts in Mali. A case-control study was carried out in which household survey data were collected from 817 MHO member households, 787 non-member households in MHO catchment areas, and 676 control households in areas without MHOs. We compiled MHO register data by household for a 22-month period. Outcome measures included utilization of priority services, health expenditures and out-of-pocket payments. Independent variables included individual, household and community demographic, socioeconomic and access characteristics, as determined through a household survey in 2004. FINDINGS: MHO members who were up to date on premium payments (controlling for education, distance to the nearest health facility and other factors) were 1.7 times more likely to get treated for fevers in modern facilities; three times more likely to take children with diarrhoea to a health facility and/or treat them with oral rehydration salts at home; twice as likely to make four or more prenatal visits; and twice as likely, if pregnant or younger than 5 years, to sleep under an insecticide-treated net (P < 0.10 or better in all cases). However, distance was also a significant negative predictor for the utilization of many services, particularly assisted deliveries. Household and individual enrolment in an MHO were not significantly associated with socioeconomic status (with the exception of the highest quintile), and MHOs seemed to provide some financial protection for their members. CONCLUSIONS: MHOs are one mechanism that countries strengthening the supply of primary care can use to increase financial access to - and equity in - priority health services