title: The impact of user fee removal policies on household out-of-pocket spending: evidence against the inverse equity hypothesis from a population based study in Burkina Faso.
abstract: BACKGROUND
  User fee removal policies have been extensively evaluated in relation to their impact on access to care, but rarely, and mostly poorly, in relation to their impact on household out-of-pocket (OOP) spending. This paucity of evidence is surprising given that reduction in household economic burden is an explicit aim for such policies. Our study assessed the equity impact on household OOP spending for facility-based delivery of the user fee reduction policy implemented in Burkina Faso since 2007 (i.e., subsidised price set at 900 Communauté Financière Africaine francs (CFA) for all, but free for the poorest). Taking into account the challenges linked to implementing exemption policies, we aimed to test the hypothesis that the user fee reduction policy had favoured the least poor more than the poor.
  
  
  METHODS
  We used data from six consecutive rounds (2006-2011) of a household survey conducted in the Nouna Health District. Primary outcomes are the proportion of households being fully exempted (the poorest 20% according to the policy) and the actual level of household OOP spending on facility-based delivery. The estimation of the effects relied on a Heckman selection model. This allowed us to estimate changes in OOP spending across socio-economic strata given changes in service utilisation produced by the policy.
  
  
  RESULTS
  A total of 2,316 women reported a delivery between 2006 and 2011. Average household OOP spending decreased from 3,827 CFA in 2006 to 1,523 in 2011, without significant differences across socio-economic strata, neither in terms of households being fully exempted from payment nor in terms of the amount paid. Payment remained regressive and substantially higher than the stipulated 900 CFA.
  
  
  CONCLUSIONS
  The Burkinabè policy led to a significant and sustained reduction in household OOP health spending across all socio-economic groups, but failed to properly target the poorest by ensuring a progressive payment system.
authors.affiliation: Département de Médecine Sociale et Préventive, Montréal School of Public Health, Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Montréal, Canada, valery.ridde@umontreal.ca.
authors.forename: V
authors.initials: V
authors.lastname: Ridde
authors.forename: I
authors.initials: I
authors.lastname: Agier
authors.forename: A
authors.initials: A
authors.lastname: Jahn
authors.forename: O
authors.initials: O
authors.lastname: Mueller
authors.forename: J
authors.initials: J
authors.lastname: Tiendrebéogo
authors.forename: M
authors.initials: M
authors.lastname: Yé
authors.forename: M
authors.initials: M
authors.lastname: De Allegri
mesh_terms: D002050:Burkina Faso; D036861:Delivery, Obstetric / Q000191:economics*; D005260:Female; D005382:Financing, Personal / Q000191:economics*; D019538:Health Care Surveys; D005102:Health Expenditures; D006297:Health Services Accessibility / Q000191:economics*; D006801:Humans; D008427:Maternal Health Services / Q000191:economics*; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011247:Pregnancy; D012959:Socioeconomic Factors