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Valery Ridde - One of the best experts on this subject based on the ideXlab platform.
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do targeted User Fee exemptions reach the ultra poor and increase their healthcare utilisation a panel study from burkina faso
International Journal of Environmental Research and Public Health, 2020Co-Authors: Y. Beaugé, Manuela De Allegri, S. Ouédraogo, Emmanuel Bonnet, N. Kuunibe, Valery RiddeAbstract:Background: A component of the performance-based financing intervention implemented in Burkina Faso was to provide free access to healthcare via the distribution of User Fee exemption cards to previously identified ultra-poor. This study examines the factors that led to the receipt of User Fee exemption cards, and the effect of card possession on the utilisation of healthcare services. Methods: A panel data set of 1652 randomly selected ultra-poor individuals was used. Logistic regression was applied on the end line data to identify factors associated with the receipt of User Fee exemption cards. Random-effects modelling was applied to the panel data to determine the effect of the card possession on healthcare service utilisation among those who reported an illness six months before the surveys. Results: Out of the ultra-poor surveyed in 2017, 75.51% received exemption cards. Basic literacy (p = 0.03), living within 5 km from a healthcare centre (p = 0.02) and being resident in Diebougou or Gourcy (p = 0.00) were positively associated with card possession. Card possession did not increase health service utilisation (β = −0.07; 95% CI = −0.45; 0.32; p = 0.73). Conclusion: A better intervention design and implementation is required. Complementing demand-side strategies could guide the ultra-poor in overcoming all barriers to healthcare access.
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economic evaluation of User Fee exemption policies for maternal healthcare in burkina faso evidence from a cost effectiveness analysis
Value in Health, 2020Co-Authors: Hoa Thi Nguyen, Aleksandra Torbica, Stephan Brenner, Joel Arthur Kiendrebeogo, Ludovic Tapsoba, Valery Ridde, Manuela De AllegriAbstract:Abstract Objectives The reduction and removal of User Fees for essential care services have recently become a key instrument to advance universal health coverage in sub-Saharan Africa, but no evidence exists on its cost-effectiveness. We aimed to address this gap by estimating the cost-effectiveness of 2 User-Fee exemption interventions in Burkina Faso between 2007 and 2015: the national 80% User-Fee reduction policy for delivery care services and the User-Fee removal pilot (ie, the complete [100%] User-Fee removal for delivery care) in the Sahel region. Methods We built a single decision tree to evaluate the cost-effectiveness of the 2 study interventions and the baseline. The decision tree was populated with an own impact evaluation and the best available epidemiological evidence. Results Relative to the baseline, both the national 80% User-Fee reduction policy and the User-Fee removal pilot are highly cost-effective, with incremental cost-effectiveness ratios of $210.22 and $252.51 per disability-adjusted life-year averted, respectively. Relative to the national 80% User-Fee reduction policy, the User-Fee removal pilot entails an incremental cost-effectiveness ratio of $309.74 per disability-adjusted life-year averted. Conclusions Our study suggests that it is worthwhile for Burkina Faso to move from an 80% reduction to the complete removal of User Fees for delivery care. Local analyses should be done to identify whether it is worthwhile to implement User-Fee exemptions in other sub-Saharan African countries.
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Do targeted User Fee exemptions reach the ultra-poor and increase their healthcare utilisation ? : a panel study from Burkina Faso
International Journal of Environmental Research and Public Health, 2020Co-Authors: Y. Beaugé, M. De Allegri, S. Ouédraogo, Emmanuel Bonnet, N. Kuunibe, Valery RiddeAbstract:A component of the performance-based financing intervention implemented in Burkina Faso was to provide free access to healthcare via the distribution of User Fee exemption cards to previously identified ultra-poor. This study examines the factors that led to the receipt of User Fee exemption cards, and the effect of card possession on the utilisation of healthcare services. Methods: A panel data set of 1652 randomly selected ultra-poor individuals was used. Logistic regression was applied on the end line data to identify factors associated with the receipt of User Fee exemption cards. Random-effects modelling was applied to the panel data to determine the effect of the card possession on healthcare service utilisation among those who reported an illness six months before the surveys. Results: Out of the ultra-poor surveyed in 2017, 75.51% received exemption cards. Basic literacy (p = 0.03), living within 5 km from a healthcare centre (p = 0.02) and being resident in Diébougou or Gourcy (p = 0.00) were positively associated with card possession. Card possession did not increase health service utilisation (ß = -0.07; 95% CI = -0.45; 0.32; p = 0.73). Conclusion: A better intervention design and implementation is required. Complementing demand-side strategies could guide the ultra-poor in overcoming all barriers to healthcare access.
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an evaluation of healthcare use and child morbidity 4 years after User Fee removal in rural burkina faso
Maternal and Child Health Journal, 2019Co-Authors: Valery Ridde, Manuela De Allegri, David Zombre, Robert W Platt, Kate ZinszerAbstract:Objectives Increasing financial access to healthcare is proposed to being essential for improving child health outcomes, but the available evidence on the relationship between increased access and health remains scarce. Four years after its launch, we evaluated the contextual effect of User Fee removal intervention on the probability of an illness occurring and the likelihood of using health services among children under 5. We also explored the potential effect on the inequality in healthcare access. Methods We used a comparative cross-sectional design based upon household survey data collected years after the intervention onset in one intervention and one comparison district. Propensity scores weighting was used to achieve balance on covariates between the two districts, which was followed by logistic multilevel modelling to estimate average marginal effects (AME). Results We estimated that there was not a significant difference in the reduced probability of an illness occurring in the intervention district compared to the non-intervention district [AME 4.4; 95% CI 1.0–9.8)]. However, the probability of using health services was 17.2% (95% CI 15.0–26.6) higher among children living in the intervention district relative to the comparison district, which rose to 20.7% (95% CI 9.9–31.5) for severe illness episodes. We detected no significant differences in the probability of health services use according to socio-economic status [χ2 (5) = 12.90, p = 0.61]. Conclusions for Practice In our study, we found that User Fee removal led to a significant increase in the use of health services in the longer term, but it is not adequate by itself to reduce the risk of illness occurrence and socioeconomic inequities in the use of health services.
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immediate and sustained effects of User Fee exemption on healthcare utilization among children under five in burkina faso a controlled interrupted time series analysis
Social Science & Medicine, 2017Co-Authors: David Zombre, Manuela De Allegri, Valery RiddeAbstract:Abstract Background Little is known about the long-term effects of User Fee exemption policies on health care use in developing countries. We examined the association between User Fee exemption and health care use among children under five in Burkina Faso. We also examined how factors related to characteristics of health facilities and their environment moderate this association. Method We used a multilevel controlled interrupted time-series design to examine the strength of effect and long term effects of User Fee exemption policy on the rate of health service utilization in children under five between January 2004 and December 2014. Results The initiation of the intervention more than doubled the utilization rate with an immediate 132.596% increase in intervention facilities (IRR: 2.326; 95% CI: 1.980 to 2.672). The effect of the intervention was 32.766% higher in facilities with higher workforce density (IRR: 1.328; 95% CI (1.209–1.446)) and during the rainy season (IRR:1.2001; 95% CI: 1.0953–1.3149), but not significant in facilities with higher dispersed populations (IRR: 1.075; 95% CI: (0.942–1.207)). Although the intervention effect was substantially significant immediately following its inception, the pace of growth, while positive over a first phase, decelerated to stabilize itself three years and 7 months later before starting to decrease slowly towards the end of the study period. Conclusion This study provides additional evidence to support User Fee exemption policies complemented by improvements in health care quality. Future work should include an assessment of the impact of User Fee exemption on infant morbidity and mortality and better discuss factors that could explain the slowdown in this upward trend of utilization rates three and a half years after the intervention onset.
Manuela De Allegri - One of the best experts on this subject based on the ideXlab platform.
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do targeted User Fee exemptions reach the ultra poor and increase their healthcare utilisation a panel study from burkina faso
International Journal of Environmental Research and Public Health, 2020Co-Authors: Y. Beaugé, Manuela De Allegri, S. Ouédraogo, Emmanuel Bonnet, N. Kuunibe, Valery RiddeAbstract:Background: A component of the performance-based financing intervention implemented in Burkina Faso was to provide free access to healthcare via the distribution of User Fee exemption cards to previously identified ultra-poor. This study examines the factors that led to the receipt of User Fee exemption cards, and the effect of card possession on the utilisation of healthcare services. Methods: A panel data set of 1652 randomly selected ultra-poor individuals was used. Logistic regression was applied on the end line data to identify factors associated with the receipt of User Fee exemption cards. Random-effects modelling was applied to the panel data to determine the effect of the card possession on healthcare service utilisation among those who reported an illness six months before the surveys. Results: Out of the ultra-poor surveyed in 2017, 75.51% received exemption cards. Basic literacy (p = 0.03), living within 5 km from a healthcare centre (p = 0.02) and being resident in Diebougou or Gourcy (p = 0.00) were positively associated with card possession. Card possession did not increase health service utilisation (β = −0.07; 95% CI = −0.45; 0.32; p = 0.73). Conclusion: A better intervention design and implementation is required. Complementing demand-side strategies could guide the ultra-poor in overcoming all barriers to healthcare access.
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economic evaluation of User Fee exemption policies for maternal healthcare in burkina faso evidence from a cost effectiveness analysis
Value in Health, 2020Co-Authors: Hoa Thi Nguyen, Aleksandra Torbica, Stephan Brenner, Joel Arthur Kiendrebeogo, Ludovic Tapsoba, Valery Ridde, Manuela De AllegriAbstract:Abstract Objectives The reduction and removal of User Fees for essential care services have recently become a key instrument to advance universal health coverage in sub-Saharan Africa, but no evidence exists on its cost-effectiveness. We aimed to address this gap by estimating the cost-effectiveness of 2 User-Fee exemption interventions in Burkina Faso between 2007 and 2015: the national 80% User-Fee reduction policy for delivery care services and the User-Fee removal pilot (ie, the complete [100%] User-Fee removal for delivery care) in the Sahel region. Methods We built a single decision tree to evaluate the cost-effectiveness of the 2 study interventions and the baseline. The decision tree was populated with an own impact evaluation and the best available epidemiological evidence. Results Relative to the baseline, both the national 80% User-Fee reduction policy and the User-Fee removal pilot are highly cost-effective, with incremental cost-effectiveness ratios of $210.22 and $252.51 per disability-adjusted life-year averted, respectively. Relative to the national 80% User-Fee reduction policy, the User-Fee removal pilot entails an incremental cost-effectiveness ratio of $309.74 per disability-adjusted life-year averted. Conclusions Our study suggests that it is worthwhile for Burkina Faso to move from an 80% reduction to the complete removal of User Fees for delivery care. Local analyses should be done to identify whether it is worthwhile to implement User-Fee exemptions in other sub-Saharan African countries.
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an evaluation of healthcare use and child morbidity 4 years after User Fee removal in rural burkina faso
Maternal and Child Health Journal, 2019Co-Authors: Valery Ridde, Manuela De Allegri, David Zombre, Robert W Platt, Kate ZinszerAbstract:Objectives Increasing financial access to healthcare is proposed to being essential for improving child health outcomes, but the available evidence on the relationship between increased access and health remains scarce. Four years after its launch, we evaluated the contextual effect of User Fee removal intervention on the probability of an illness occurring and the likelihood of using health services among children under 5. We also explored the potential effect on the inequality in healthcare access. Methods We used a comparative cross-sectional design based upon household survey data collected years after the intervention onset in one intervention and one comparison district. Propensity scores weighting was used to achieve balance on covariates between the two districts, which was followed by logistic multilevel modelling to estimate average marginal effects (AME). Results We estimated that there was not a significant difference in the reduced probability of an illness occurring in the intervention district compared to the non-intervention district [AME 4.4; 95% CI 1.0–9.8)]. However, the probability of using health services was 17.2% (95% CI 15.0–26.6) higher among children living in the intervention district relative to the comparison district, which rose to 20.7% (95% CI 9.9–31.5) for severe illness episodes. We detected no significant differences in the probability of health services use according to socio-economic status [χ2 (5) = 12.90, p = 0.61]. Conclusions for Practice In our study, we found that User Fee removal led to a significant increase in the use of health services in the longer term, but it is not adequate by itself to reduce the risk of illness occurrence and socioeconomic inequities in the use of health services.
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immediate and sustained effects of User Fee exemption on healthcare utilization among children under five in burkina faso a controlled interrupted time series analysis
Social Science & Medicine, 2017Co-Authors: David Zombre, Manuela De Allegri, Valery RiddeAbstract:Abstract Background Little is known about the long-term effects of User Fee exemption policies on health care use in developing countries. We examined the association between User Fee exemption and health care use among children under five in Burkina Faso. We also examined how factors related to characteristics of health facilities and their environment moderate this association. Method We used a multilevel controlled interrupted time-series design to examine the strength of effect and long term effects of User Fee exemption policy on the rate of health service utilization in children under five between January 2004 and December 2014. Results The initiation of the intervention more than doubled the utilization rate with an immediate 132.596% increase in intervention facilities (IRR: 2.326; 95% CI: 1.980 to 2.672). The effect of the intervention was 32.766% higher in facilities with higher workforce density (IRR: 1.328; 95% CI (1.209–1.446)) and during the rainy season (IRR:1.2001; 95% CI: 1.0953–1.3149), but not significant in facilities with higher dispersed populations (IRR: 1.075; 95% CI: (0.942–1.207)). Although the intervention effect was substantially significant immediately following its inception, the pace of growth, while positive over a first phase, decelerated to stabilize itself three years and 7 months later before starting to decrease slowly towards the end of the study period. Conclusion This study provides additional evidence to support User Fee exemption policies complemented by improvements in health care quality. Future work should include an assessment of the impact of User Fee exemption on infant morbidity and mortality and better discuss factors that could explain the slowdown in this upward trend of utilization rates three and a half years after the intervention onset.
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understanding home delivery in a context of User Fee reduction a cross sectional mixed methods study in rural burkina faso
BMC Pregnancy and Childbirth, 2015Co-Authors: Manuela De Allegri, Albrecht Jahn, Justin Tiendrebeogo, Olaf Muller, Valery RiddeAbstract:Background Several African countries have recently reduced/removed User Fees for maternal care, producing considerable increases in the utilization of delivery services. Still, across settings, a conspicuous number of women continue to deliver at home. This study explores reasons for home delivery in rural Burkina Faso, where a successful User Fee reduction policy is in place since 2007.
Y. Beaugé - One of the best experts on this subject based on the ideXlab platform.
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do targeted User Fee exemptions reach the ultra poor and increase their healthcare utilisation a panel study from burkina faso
International Journal of Environmental Research and Public Health, 2020Co-Authors: Y. Beaugé, Manuela De Allegri, S. Ouédraogo, Emmanuel Bonnet, N. Kuunibe, Valery RiddeAbstract:Background: A component of the performance-based financing intervention implemented in Burkina Faso was to provide free access to healthcare via the distribution of User Fee exemption cards to previously identified ultra-poor. This study examines the factors that led to the receipt of User Fee exemption cards, and the effect of card possession on the utilisation of healthcare services. Methods: A panel data set of 1652 randomly selected ultra-poor individuals was used. Logistic regression was applied on the end line data to identify factors associated with the receipt of User Fee exemption cards. Random-effects modelling was applied to the panel data to determine the effect of the card possession on healthcare service utilisation among those who reported an illness six months before the surveys. Results: Out of the ultra-poor surveyed in 2017, 75.51% received exemption cards. Basic literacy (p = 0.03), living within 5 km from a healthcare centre (p = 0.02) and being resident in Diebougou or Gourcy (p = 0.00) were positively associated with card possession. Card possession did not increase health service utilisation (β = −0.07; 95% CI = −0.45; 0.32; p = 0.73). Conclusion: A better intervention design and implementation is required. Complementing demand-side strategies could guide the ultra-poor in overcoming all barriers to healthcare access.
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Do targeted User Fee exemptions reach the ultra-poor and increase their healthcare utilisation ? : a panel study from Burkina Faso
International Journal of Environmental Research and Public Health, 2020Co-Authors: Y. Beaugé, M. De Allegri, S. Ouédraogo, Emmanuel Bonnet, N. Kuunibe, Valery RiddeAbstract:A component of the performance-based financing intervention implemented in Burkina Faso was to provide free access to healthcare via the distribution of User Fee exemption cards to previously identified ultra-poor. This study examines the factors that led to the receipt of User Fee exemption cards, and the effect of card possession on the utilisation of healthcare services. Methods: A panel data set of 1652 randomly selected ultra-poor individuals was used. Logistic regression was applied on the end line data to identify factors associated with the receipt of User Fee exemption cards. Random-effects modelling was applied to the panel data to determine the effect of the card possession on healthcare service utilisation among those who reported an illness six months before the surveys. Results: Out of the ultra-poor surveyed in 2017, 75.51% received exemption cards. Basic literacy (p = 0.03), living within 5 km from a healthcare centre (p = 0.02) and being resident in Diébougou or Gourcy (p = 0.00) were positively associated with card possession. Card possession did not increase health service utilisation (ß = -0.07; 95% CI = -0.45; 0.32; p = 0.73). Conclusion: A better intervention design and implementation is required. Complementing demand-side strategies could guide the ultra-poor in overcoming all barriers to healthcare access.
Martin Kolmar - One of the best experts on this subject based on the ideXlab platform.
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Endogenous free riding and the decentralized User-Fee financing of spillover goods in a n-region economy
International Tax and Public Finance, 2013Co-Authors: Clemens Fuest, Martin KolmarAbstract:The paper analyzes the strategic effects of decentralized User-Fee and enforcement policies for the financing of interregional spillover goods. We derive the equilibrium pricing and enforcement rules for a n -region economy. We show that under mild conditions on the pattern of substitution between spillover goods and contrary to the 2-region case, the decentralized equilibrium cannot be Pareto improved by coordinated policy changes. However, decentralized equilibria are suboptimal from the point of view of utilitarian welfare. We characterize the direction of the distortion for this case. The regions’ incentives for User-Fee enforcement are ambiguous in general. With only two regions and if regions only charge non-residents, however, there is overinvestment in User-Fee enforcement in the decentralized equilibrium. For the case of a Tullock enforcement function and linear demand for the spillover goods we show that welfare is u-shaped in a parameter that measures the technological advantage of User-Fee enforcement.
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A Theory of User-Fee Competition
Journal of Public Economics, 2007Co-Authors: Clemens Fuest, Martin KolmarAbstract:We develop a two-region model where the decentralized provision of spillover goods and other public expenditures is financed by means of User Fees. We show that a decentralized solution tends to be inefficient. If the regional spillover goods are substitutes, User Fees tend to be inefficiently low, whereas they tend to be inefficiently high if the spillover goods are complements.
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A Theory of User-Fee Competition
2004Co-Authors: Clemens Fuest, Martin KolmarAbstract:We develop a two-region model where the decentralized provision of spillover goods can be financed by means of taxes or User Fees. In order to enforce the Fees regions have to invest in exclusion. We show that a decentralized solution tends to be inefficient. There will be over-investment in exclusion and an underprovision of the spillover goods compared to a centralized solution. In addition the regions have strategic incentives to set User charges. If the regional spillover goods are substitutes User Fees tend to be inefficiently low, whereas they tend to be inefficiently high if the spillover goods are complements.
Lucy Gilson - One of the best experts on this subject based on the ideXlab platform.
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User Fee removal in low income countries sharing knowledge to support managed implementation
Health Policy and Planning, 2011Co-Authors: Bruno Meessen, Lucy Gilson, Abdelmajid TiboutiAbstract:User Fees have triggered impassioned discussions in international health over the last two decades. Promoted by a number of international organizations since the late 1980s as a strategy to finance struggling public health facilities in many lowincome countries, recent years have seen growing criticism of the impact of Fees on access to health services, particularly for the poorest groups. The debate continues and there is evidence for both sides of the argument. User Fees are a barrier to Users, and the poor in particular, but they also have some valuable characteristics (Meessen et al. 2006). Their contribution to generating resources for the benefit of health facilities that are sometimes deprived of any other source of flexible funding is just the most obvious one. Taking the right stance in this debate is far from easy for countries and their aid partners, as different constraints—including country ownership, fiscal space, other pressing development needs and the obligation to ration available resources—have to be taken into account. In 2005, UNICEF organized an expert consultation to update its position on this controversial strategy. The evidence reviewed at this consultation led to the following consensus: removing User Fees has the potential to improve access to health services, especially for the poor. For this to occur, however, Fee removal needs to be part of a broader package of reforms that includes increased budgets to offset lost Fee revenue, maintain quality and respond to increased demand. It also needs clear communication with a broad stakeholder buy-in, careful monitoring to ensure that official Fees are not replaced by informal Fees, and appropriate management of the alternative financing mechanisms which are replacing User Fees. When the above conditions are not met, Fee removal is unlikely to benefit the poor (James et al. 2006). In mid-2008, UNICEF approached a group of researchers with the request to document recent experience with User Fee removal. While aid actors in the North were still arguing fiercely about the pros and cons of User Fees, a growing number of countries had already decided to remove User Fees, at least for some priority services. A consensus was easily reached between UNICEF and the research team led by the Institute of Tropical Medicine, Antwerp: the multi-country review would not (again) focus on evidence against or in favour of User Fees, but would instead try to document how countries formulated and implemented User Fee removal. This focus was seen as valuable because it could generate practical lessons for other countries interested in such a step. The findings of the multi-country review were presented at a meeting of experts convened by UNICEF New York in February 2009. Presentations covered a number of countries as well as comparisons between countries—including a challenging comparison between Rwanda and Uganda. At some point, the ‘ghosts’ of Bismark and Beveridge entered the room, so there was another episode in the (by now familiar) debate on the relative merits of reducing financial barriers through health insurance or through User Fee removal. We do have some country evidence to fuel this broader debate in this supplement; however, its main focus lies elsewhere. Following the New York meeting, the research team judged that the main question of the multi-country review—the challenges related to design and implementation of User Fee removal policies—deserved more visibility than just another report. Indeed, while there is a large consensus among experts familiar with health systems in low-income countries that implementation of new policies and interventions raises major challenges (Peters et al. 2009), the formally published knowledge base is still small (Gilson and Raphaely 2008). Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine The Author 2011; all rights reserved. Health Policy and Planning 2011;26:ii1–ii4 doi:10.1093/heapol/czr071
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User Fee policies to promote health service access for the poor a wolf in sheep s clothing
International Journal of Health Services, 1997Co-Authors: Steven Russell, Lucy GilsonAbstract:An international survey of health service User Fee and exemption policies in 26 low- and middle-income countries assessed whether User Fee policies were supported by measures that protect the poor. In particular, it explored whether governments were introducing a package of supportive measures to promote service improvements that benefit disadvantaged groups and tackle differential ability to pay through an effective series of exemptions. The results show that many countries lack policies that promote access for disadvantaged groups within User Fee systems and quality improvements such as revenue retention at the health care facility and expenditure guidelines for local managers. More significant policy failures were identified for exemptions: 27 percent of countries had no policy to exempt the poor; in contrast, health workers were exempted in 50 percent of countries. Even when an official policy to exempt the poor existed, there were numerous informational, administrative, economic, and political constr...
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the lessons of User Fee experience in africa
Health Policy and Planning, 1997Co-Authors: Lucy GilsonAbstract:This paper reviews the experience of implementing User Fees in Africa. It describes the two main approaches to implementing User Fees that have been applied in African countries, the standard and the Bamako Initiative models, and their common objectives. It summarizes the evidence concerning the impact of Fees on equity, efficiency and system sustainability (as opposed to financial sustainability), and the key bottlenecks to their effective implementation. On the basis of this evidence it then draws out three main sets of lessons, focusing on: where and when to implement Fees; how to enhance the impact of Fees on their objectives; and how to strengthen the process of implementation. If introduced by themselves, Fees are unlikely to achieve equity, efficiency or sustainability objectives. They should, therefore, be seen as only one element in a broader health care financing package that should include some form of risk-sharing. This financing package is important in limiting the potential equity dangers clearly associated with Fees. There is a greater potential role for Fees within hospitals rather than primary facilities. Achievement of equity, efficiency and, in particular, sustainability will also require the implementation of complementary interventions to develop the skills, systems and mechanisms of accountability critical to ensure effective implementation. Finally, the process of policy development and implementation is itself an important influence over effective implementation.
