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01.12.2012 | Research | Ausgabe 1/2012 Open Access

International Journal for Equity in Health 1/2012

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

International Journal for Equity in Health > Ausgabe 1/2012
Marianne El-Khoury, Laurel Hatt, Timothee Gandaho
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​1475-9276-11-49) contains supplementary material, which is available to authorized users.

Competing interests

The authors declare that they have no competing interests. The opinions expressed herein are the authors’ and do not necessarily reflect the views of Abt Associates Inc. or the U.S. Agency for International Development (USAID). All errors remain the responsibility of the authors.

Authors’ contributions

MEK analyzed and interpreted the data and drafted the manuscript. LH made significant contributions to the data interpretation and analysis and revised the manuscript critically for important intellectual content. TG participated in the original design of the study and the coordination of data collection in the field and was involved in revising the manuscript. All authors read and approved the final manuscript.



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.


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.


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.


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