Over 25 years have passed since the Bamako statement was adopted by African health ministers in Bamako, Mali, to implement strategies designed to increase the availability of essential drugs and other healthcare services with the aim of improving primary health care. As we move toward a post-2015 agenda for health and a push for universal health coverage gains primacy, the FEMHealth project provides some insights into the impact, cost and effectiveness of the removal of user fees for delivery care on maternal and neonatal health outcomes and service quality in three West African countries (Benin, Burkina Faso, Mali) and Morocco.

Drivers of fee exemption policies

One of our research areas focussed on the emergence of similar fee exemption policies across the region in recent years. Why had so many selective fee exemptions proliferated over a short period in what had been the Bamako Initiative heartland? One hypothesis was international partner pressure was the catalyst, but in fact our health policy analysis found that policies were home-grown. There was some evidence of distrust of external advice given the record of changing prescriptions on user fees over the past decades.

Did they improve access to services and protect families from catastrophic health expenditure?

Although families continued to pay for items (such as medicines) which should have been exempt (to varying degrees in the four countries), substantial reductions in household payments were found, suggesting that the financial protection goals of the policy may have been more successful than the health ones. Analysis of long term trends in utilisation of facility deliveries and caesareans found a continuation of previous trends in three countries for which data was available. Equity gaps also continue to close at a constant rate, with no evidence of a policy-related shift. Awareness of policies and specific entitlements was low, even amongst women who had delivered – one of the areas requiring improved action.

Policy design pitfalls

The policies in the countries under study – Burkina Faso, Benin, Mali and Morocco – focussed heavily on caesarean sections (in Mali and Benin these were the principal service exempted for all). This carries dangers – not only do caesareans only respond to a portion of the causes of maternal death, they are also heavily biased towards the rich, in terms of use prior to the policies being introduced. Our results found a corresponding bias in favour of better off households in a number of the countries.

Quality of care: up or down?

In relation to the effects on quality of care and health outcomes in facilities of removing fees, there were two contradictory expectations – that it might improve it, due to quicker access for women, and that it might degrade it, due to greater pressure on staff and other resources. In practice, cross-sectional analysis linking quality and outcomes with implementation of the policy suggests that in some countries the relationship was positive and in the others it was varied by site. Generally, quality of care for newborns was less acceptable than for mothers. Even where technical quality of care was good, interpersonal care was sometimes poor – another key factor which deters women from delivering in facilities.

Implementation and finance issues

Based on prior experience in other countries, problems of financing gaps and of flawed implementation of policies were expected, but happily this was not generally the case in the countries that we studied. Policies were domestically financed, there was no evidence of funding gaps, and effort put into implementation systems. As a proportion of public health expenditure in 2011, the policies absorbed around 2.5% in Morocco, 3% in Benin and 3.5% in Burkina Faso – not insignificant but all potentially sustainable.

Taking a broader view: health systems effects

We looked for wider systems effects and unintended effects on other users but found no systematic effects. Staff on the whole supported the policies, despite our expectations of opposition. What was striking was that within each country, there were considerable variations in performance across areas and facilities. This emphasises the importance of local context and the institutional and organisational frameworks into which policies are introduced. Measures to boost local stewardship can not only improve implementation of these policies but the functioning of the system as a whole.

Top ten recommendations arising from the research

1. Governments should extend exemption and subsidy policies but should ensure that they cover a package of care which addresses all of the main causes of maternal and neonatal morbidity and mortality
2. They should work with providers to raise the quality of care provided, particularly for the newborn, and not neglecting the interpersonal skills which are so important to users
3. Policies need to be clearly communicated to health staff and the community
4. Provider payments need to be correctly calibrated so as to create the right incentives
5. Managers, staff and communities should be involved in developing and monitoring the policy in order to increase ownership and control abuse
6. All countries need to more effectively regulate providers to stop illicit payments from being demanded of patients
7. Additional actions are needed to ensure that benefits can be equitable – in particular, paying attention to transport and access to facilities at night
8. Underlying systemic weaknesses which undermine policy effectiveness need to be addressed. These include, for example, drugs supply and distribution systems which are not reliable and poor provider-patient relationships.
9. There should be a focus on enabling effective stewardship at the local level by reinforcing competences and setting up institutional arrangements to enable positive management of resources.
10. All exemption and financial protection policies should be embedded in an overall national plan to achieve universal health coverage, and should not add to the fragmentation of the health financing architecture.

About FEMHealth

FEMHealth was a multi-country, multi-institutional research project, launched in 2011 with EU funding to study national policies for obstetric fee exemption in West Africa.

The overall aims of the project were: (1) to develop new methodological approaches for the evaluation of complex interventions in low income countries, (2) to improve the health of mothers and their newborns by performing comprehensive evaluations of the impact, cost and effectiveness of the removal of user fees for delivery care on maternal and neonatal health outcomes and service quality, and (3) to improve the communication of this evidence to policy-makers and other stakeholders.

To read some ideas how, read our final report and brief here.

We have also supported the establishment of the Financial Access to Health Services Community of Practice as part of our communication work. For some practical lessons on facilitating a virtual community, visit our website.

By Sophie Witter – FEMHealth scientific coordinator