No effect of user fee exemption on perceived quality of delivery care in Burkina Faso: a case-control study

Concerned with the consequences of user fees in African countries, in 2010 the African Union decided to remove user fees in order to enhance access to maternal health care [1]. Indeed, user fee strategies, introduced since the 80s, have generally been shown to impede access to health care, particularly for poor and vulnerable population groups that failed to meet health care costs [2‐4]. Fees have been pointed out as contributing to the impoverishment of vulnerable households and increasing pre-existing inequalities [5, 6]. Following an emerging international consensus on the removal of user fees, some African countries have adopted a fee abolition policy [7, 8]. The resulting growing utilization of health care facilities for deliveries after partial or total fee exemption [9, 10] has been accompanied by a significant loss of income for health care facilities. To compensate for this lack of income while ensuring the maintenance of services and anticipating growth in demand, several health care facilities have reduced the quality of care services and/or reinstated payment through informal practices [11‐15]. Decreased quality in delivery care services may be the result of increased workload or declining staff morale, particularly when the implementation of the exemption policy is not accompanied by a commensurate increase in human, material and financial resources [16]. This type of decline in care service quality may cause frustration among patients [17], especially the poorest women, who usually suffer poor treatment, as health workers are likely to give preference to wealthy women who offer tips and bribes [18]. Although many studies have centered on care providers’ satisfaction in Africa [19‐21], little emphasis has been placed on patients’ satisfaction in the new context of elimination of user fees [22].

Since 2006, Burkina Faso has implemented a national subsidy policy that covers 80% of fees for skilled deliveries in primary health care centres (Health and Social Promotion Centres, or CSPS), but the remainder must still be paid by the women [23]. In 2008, the German non-governmental organization (HELP) introduced a supplementary subsidy (20%) in the health districts of Sebba and Dori, thus ensuring totally free care at the point of use. It remains be to verified whether quality of care was maintained for everyone after total removal of fees. Thus, the present study attempts to gather evidence on satisfaction with quality of care of skilled delivery for women who benefited from total fee exemption and those who did not (still paying 20% of fees).

The three dimensions that were captured from a PCA analysis corresponded to those of some other studies [26, 27] and supported our findings. Patients are often inclined by courtesy to respond positively to questions on satisfaction with the quality of care received [28]. This level of courtesy is even higher for satisfaction on interpersonal relationships between care providers and patients. This aspect is the most influential aspect of satisfaction in our indices, as seen in the greatest variance of responses. In a complex technical sector like health care, patients are capable of evaluating neither the level of expertise and basic technical competences of neither their care providers nor the structural quality of care. Thus, it is normal that technical or functional quality ratings in patients were generally high and failed to discordance (quality of nursing care). However, the wealthiest women were more likely to be dissatisfied with the physical conditions of the delivery environment, which generally relates to the lack of financial support of the government state rather than the technical capabilities of care providers. The appearance of the health care centre is important, as patients expect a sense of order and discipline in the environment [29].

All the women who were interviewed demonstrated high levels of satisfaction in both the intervention and control groups, with the exception of a few items (3 out of 34). On half of the items, satisfaction was even greater for the women in the intervention group. Another study [30] showed that despite the increased use of birth delivery services in Dori (intervention group) caused by the abolition of fees, the number of health workers exceeded the number required to conduct delivery activities. Moreover, the fact that the overall satisfaction of delivery care was evaluated three years after the introduction of total fee exemption points to the sustainable effect of that intervention. It would be too ambitious to say that total fee exemption is the only factor responsible for a greater (although not significant) satisfaction. These results suggest that insofar as a substantial financial burden is relieved with total fee exemption at the point of use, while being integrated into a functioning health care system, including community awareness, quality of health workers and infrastructure, quality of care should not be affected, patients’ needs are met, and thus satisfaction is guaranteed. These findings are consistent with other studies showing that greater access to health care is generally associated with increased service utilization and reduced costs for households and more positive impressions [31]. However, this certainly cannot be generalized to all countries in West Africa, as the number of care providers is generally higher in Burkina Faso than observed in neighbouring countries such as Niger and Mali, which respectively had two and five times fewer nurses and midwives than Burkina Faso (mean 7.3 per 10,000 inhabitants) [32].

Total delivery fee exemption seems to benefit all categories of wealth without reinforcing inequalities between very poor and wealthy women in relation to access to delivery care quality, as found in another study in Burkina Faso [31]. Interestingly, the wealthiest women were even more dissatisfied with the delivery environment than the poorest ones, whereas the poorest women demonstrated higher satisfaction with nursing care. The fact that very few, if any, private health centres exist in the study region may partly explain the tendency for the wealthiest women to be less pleased than the poorest ones, as their needs or expectations cannot be met, especially when they contribute to the fees. However, it is interesting to note that in general, the wealthiest women were more likely to be very dissatisfied than the poorest ones, and on the contrary, the poorest women demonstrated higher satisfaction than the wealthiest women.

The quasi-experimental design approach of intervention versus control health districts adopted in the present study may suffer from a number of limitations, and therefore our results must be interpreted cautiously. This survey has introduced a potential for bias from the realities of sampling. Several households were not sampled due to limited access caused by flooding and/or the remoteness of some hamlets. Some bias may also have originated from hypothetical intimidation by the male interviewer of some women. It also remains possible that the interpretation of questionnaires was different between patients, which may affect the generalizability of our findings. Finally, the errors or omissions in the lists taken from the records of the primary health care facilities were beyond our control.

Despite the recommendations of the African Union [1], abolition of delivery fees is not unanimous, especially among the policy makers in West Africa. Beyond the issues of funding such a policy, it is often the same principle that is denounced, i.e. some going so far as to say that abolition of delivery fees would encourage births in Burkina Faso. While several studies in Burkina Faso [10, 31] have shown that total fee exemption increased skilled deliveries at health facilities, which is an essential element of the fight against maternal mortality, the present study demonstrated that there was no difference in perceived quality of care. The effectiveness of that principle having been proved, it would certainly help to make it nationwide and fulfill the commitments made by the head of state of Burkina Faso, who announced in 2010 that financial barriers to access to maternal health care would be removed.