The Africa Initiative is a multi-year, donor-supported program, with three components: a research program, an exchange program and an online knowledge hub, the Africa portal.
The Centre for International Governance innovation (CIGI) is an independent, non-partisan think tank on international governance.
June 2013
Introduction
In West Africa, women have had to pay for antenatal care consultations and deliveries in health centers since the 1980s, a system known as user fees. This mode of financing imposes a financial barrier for poor households to obtain necessary health care. Evidence has shown that delivery in a health centre with qualified staff reduces maternal and infant mortality. Hence, different agencies of the United Nations and the African Union (AU) have joined forces to call for the abolition of user fees for delivery (AU, 2010; The Global Campaign for the Health Millennium Development Goals [MDGs]).
Since the 1990s, there has been a wave of public policies promoting user fee abolition for antenatal care and delivery in multiple East and Southern African countries. In West Africa, such policies, in particular for delivery, are relatively recent.
For instance, in Mali, Benin and Senegal, women are not required to pay for C-sections. In Burkina Faso, the government decreased the fees for delivery rather than abolish them completely, so women must pay 20 percent of the total cost. Recent research reveals that these policies often represent an efficient means of increasing service utilization but that there are barriers to their effective implementation.
The political decision to reduce or eliminate user fees is usually taken rapidly, leaving little time for planning the implementation. Since these decisions are politically driven, there has been inadequate involvement of service providers (as implementers) in policy design.
Published evidence has thus far provided limited information about what factors lead decision makers to design and implement user-fee abolition policies. Retrospective qualitative studies are useful in identifying the processes leading to a decision; however, these studies suffer from obvious methodological limitations, given the challenges encountered when reconstructing events in the past. Ideally, since African countries operate in a context of scarce resources and are unable to abolish user fees for all health care services, well-defined criteria should guide policy decisions on user-fee abolition.
This study assesses the criteria policy entrepreneurs regard as most and least important in guiding their decisions on user-fee abolition or reduction. It focuses exclusively on maternal care, an area where user fees have mostly been abolished for this set of services.
Results
The initial results suggest that political commitment and impact on health are the most important criteria, followed by burden of disease and increase in service utilization. International pressure and donor money were considered the least important criteria.
It is interesting to note that only a very small proportion of individuals (13 percent) indicated that donor money and international pressure should be considered, while the majority questioned why these two criteria were even suggested (<70 percent). The majority of participants (65.8 percent) reported that political commitment guided decision making in their country. It ought to be noted that institutional capacity was not considered at all important in the validation part of the survey.
Discussion
This is the first study undertaken to identify the agenda-setting criteria guiding policy decisions of African policy entrepreneur on user-fee abolition for maternal care services. Due to the small number of respondents, the authors are cautious about the interpretation and drawing generalized conclusions from the study results.
Those participating in the workshop in Bamako are not representatives of all policy entrepreneurs in West Africa. Moreover, it is important to acknowledge that the majority of respondents were not actual decision makers in their countries; in many cases, ministers and presidents, rather than officials, make decisions. Thus, this study reflects primarily the policy making criteria valued by the policy entrepreneurs to decision makers, rather than by the decision makers themselves.
Nevertheless, the authors know that the policy-making process in Africa and elsewhere is not linear and is heavily influenced by experts and technical advisers. Therefore, understanding the viewpoint of maternal health policy entrepreneurs on the criteria that should and do influence user-fee abolition policies represents a relevant concern.
This study confirms historical findings from empirical studies in many African countries that national political commitment is at the core of the decision to abolish maternal health fees. This has been the case in South Africa, one of the first countries to abolish user fees for maternal care in 1994, and in Mali and Niger in the early 2000s when these policies were presented as “gifts” to the general population. In February 2012, Côte d’Ivoire abolished user fees for women in spite of skepticism by experts that enforcement efforts and accompanying measures in the country are not yet up for the challenge.
Participants confirmed that political commitment to abolish user fees was behind policy changes in their country.
Unexpectedly, respondents attributed little importance to the role of institutional health system capacity in guiding policy decisions on user-fee abolition. This reflected a general attitude of considering the implementation of policy as something that would follow from a political decision — “if the political decisions are taken, the implementation will follow” in accordance with the theories of rational choice in political sciences.
This finding is worrisome, as it is well established that the implementation of such policies frequently faces serious difficulties caused by deficient preparation, lack of funding and a health system that is not always able to respond to the increase in demand induced by user-fee abolition. As a consequence, policies do at times fail due to lack of preparation and this provides an opportunity to those who oppose user-fee abolition to criticize the policy itself, even though its ability to improve access to care has long been scientifically proven.
Thus, politicians are faced with a dilemma: abolishing user fees for vulnerable population groups pleases their voters, but insufficient preparation for adequate implementation can alienate those voters and provide ammunition for the politicians’ critics, not to mention fail to meet the maternal health needs of their populations.
Finally, impact on health was ranked at the top of the list, while equity was surprisingly not ranked as high. The first may be due to the fact that the achievement of the MDGs has driven much of the development of national policies in the last 10 years. If this was actually the case, it would suggest that the absence of any international pressure was reflected as a normative discourse by the participants.
These policies have been viewed as a quick impact model by governments and donors alike, leading to the policy being put in place before adequate preparation has been made. The equity ranking also reflects current policies that are, for the most part, aligned with the MDGs to target vulnerable groups, such as women, but not to take into consideration existing inequities within these groups.
The abolition of user fees is one of the few public policies geared toward guaranteeing that the poorest women and those living the farthest away from health centers also benefit from reforms. Most public policies try to improve the health of the general population without taking into consideration health inequities among different segments of the population, in spite of the fact that such consideration should constitute a primary goal of any public health intervention (World Health Organization [WHO]). During the International Conference on Primary Health Care and Health Systems in Africa, held in Ouagadougou in April 2008, the importance of improving equity in health care was reinforced (WHO, 2008b).
In order to achieve a paradigm shift and a “third wave health research” (Ostlin et al., 2011), qualitative studies should be pursued to understand why these policy makers have not considered to a greater extent the question of equity as an influential factor for policy decision making.
Conclusion
Abolishing user fees at point of service for vulnerable populations is one solution for improving access to care and moving toward universal coverage. This is important in maternal health since delivery in a health centre with qualified staff reduces maternal and infant mortality and many people cannot afford to pay for health care. This study’s participants, mainly policy entrepreneurs, expressed that political commitment and the desire to improve the general health status of the population are the most important criteria guiding the development of user fee abolition policies.
Nevertheless, the findings suggest that for political commitment to become a reality, two strategies have to be set in place: first, equity considerations have to mediate the policy implementation to counteract existing inequities within population subgroups; second, policy decisions have to be accompanied by adequate implementing measures and receive the necessary funding.
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