title: Financial accessibility and user fee reforms for maternal healthcare in five sub-Saharan countries: a quasi-experimental analysis.
abstract: OBJECTIVE
  Evidence on whether removing fees benefits the poorest is patchy and weak. The aim of this paper is to measure the impact of user fee reforms on the probability of giving birth in an institution or undergoing a caesarean section (CS) in Ghana, Burkina Faso, Zambia, Cameroon and Nigeria for the poorest strata of the population.
  
  
  METHODS
  Women's experience of user fees in 5 African countries.
  
  
  METHODS
  Using quasi-experimental regression analysis we tested the impact of user fee reforms on facilities' births and CS differentiated by wealth, education and residence in Burkina Faso and Ghana. Mapping of the literature followed by key informant interviews are used to verify details of reform implementation and to confirm and support our countries' choice.
  
  
  METHODS
  We analysed data from consecutive surveys in 5 countries: 2 case countries that experienced reforms (Ghana and Burkina Faso) by contrast with 3 that did not experience reforms (Zambia, Cameroon, Nigeria).
  
  
  RESULTS
  User fee reforms are associated with a significant percentage of the increase in access to facility births (27 percentage points) and to a much lesser extent to CS (0.7 percentage points). Poor (but not the poorest), and non-educated women, and those in rural areas benefitted the most from the reforms. User fees reforms have had a higher impact in Burkina Faso compared with Ghana.
  
  
  CONCLUSIONS
  Findings show a clear positive impact on access when user fees are removed, but limited evidence for improved availability of CS for those most in need. More women from rural areas and from lower socioeconomic backgrounds give birth in health facilities after fee reform. Speed and quality of implementation might be the key reason behind the differences between the 2 case countries. This calls for more research into the impact of reforms on quality of care.
authors.affiliation: Department of Social Policy, LSE, London, UK.
authors.forename: Tiziana
authors.initials: T
authors.lastname: Leone
authors.affiliation: Department of Social Policy, LSE, London, UK.
authors.forename: Valeria
authors.initials: V
authors.lastname: Cetorelli
authors.affiliation: Department of Social Statistics, University of Southampton, Southampton, UK.
authors.forename: Sarah
authors.initials: S
authors.lastname: Neal
authors.affiliation: Department of Social Statistics, University of Southampton, Southampton, UK.
authors.forename: Zoë
authors.initials: Z
authors.lastname: Matthews
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara; D002050:Burkina Faso; D002585:Cesarean Section; D036861:Delivery, Obstetric / Q000191:economics*; D004522:Educational Status; D005249:Fees and Charges; D005260:Female; D005869:Ghana; D018166:Health Care Reform; D005102:Health Expenditures; D006268:Health Facilities; D006297:Health Services Accessibility / Q000191:economics*; D006700:Home Childbirth; D006801:Humans; D008427:Maternal Health Services / Q000191:economics*; D011203:Poverty; D011247:Pregnancy; D012111:Residence Characteristics; D012424:Rural Population; D012923:Social Class; D011795:Surveys and Questionnaires
keywords: Africa; Equity; Universal health care; c-section; maternal health; user fees
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