title: Cost and impact of policies to remove and reduce fees for obstetric care in Benin, Burkina Faso, Mali and Morocco.
abstract: Across the Africa region and beyond, the last decade has seen many countries introducing policies aimed at reducing financial barriers to obstetric care. This article provides evidence of the cost and effects of national policies focussed on improving financial access to caesarean and facility deliveries in Benin, Burkina Faso, Mali and Morocco.
  
  
  
  The study uses a comparative case study design with mixed methods, including realist evaluation components. This article presents results across 14 different data collection tools, used in 4-6 research sites in each of the four study countries over 2011-13. The methods included: document review; interviews with key informants; analysis of secondary data; structured extraction from medical files; cross-sectional surveys of patients and staff; interviews with patients and observation of care processes.
  
  
  
  The article finds that the policies have contributed to continued increases in skilled birth attendance and caesarean sections and a narrowing of inequalities in all four countries, but these trends were already occurring so a shift cannot be attributed solely to the policies. It finds a significant reduction in financial burdens on households after the policy, suggesting that the financial protection objectives may have been met, at least in the short term, although none achieved total exemption of targeted costs. Policies are domestically financed and are potentially sustainable and efficient, and were relatively thoroughly implemented. Further, we find no evidence of negative effects on technical quality of care, or of unintended negative effects on untargeted services.
  
  
  
  We conclude that the policies were effective in meeting financial protection goals and probably health and equity goals, at sustainable cost, but that a range of measures could increase their effectiveness and equity. These include broadening the exempted package (especially for those countries which focused on caesarean sections alone), better calibrated payments, clearer information on policies, better stewardship of the local health system to deal with underlying systemic weaknesses, more robust implementation of exemptions for indigents, and paying more attention to quality of care, especially for newborns.
authors.affiliation: Immpact programme, University of Aberdeen, Aberdeen, AB25 2ZD, Scotland, UK.|ReBUILD, Institute for Global Health and Development, Queen Margaret University, Edinburgh, EH21 6UU, Scotland, UK.
authors.forename: S
authors.initials: S
authors.lastname: Witter
authors.affiliation: ENSP, Rue Lamfadel Cherkaoui, Madinat Al Irfane, BP: 6329, Rabat, Morocco. chakib.boukhalfa@gmail.com.
authors.forename: C
authors.identifier: 0000-0001-6562-4189
authors.initials: C
authors.lastname: Boukhalfa
authors.affiliation: MARCH Centre for Maternal, Adolescent, Reproductive & Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK.
authors.forename: J A
authors.initials: JA
authors.lastname: Cresswell
authors.affiliation: MARIKANI, BP 2753, Rue 600, Porte 335 Baco djicoroni, ACI Bamako, Mali.
authors.forename: Z
authors.initials: Z
authors.lastname: Daou
authors.affiliation: Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT, London, UK.
authors.forename: V
authors.initials: V
authors.lastname: Filippi
authors.affiliation: AFRICSanté, 773 Rue Guillaume Ouédraogo, BP 298, Bobo-Dioulasso, Burkina Faso.
authors.forename: R
authors.initials: R
authors.lastname: Ganaba
authors.affiliation: Centre de Recherche en Reproduction Humaine et en Démographie, 06BP567, Cotonou, Benin.
authors.forename: S
authors.initials: S
authors.lastname: Goufodji
authors.affiliation: MARCH Centre for Maternal, Adolescent, Reproductive & Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK.
authors.forename: I L
authors.initials: IL
authors.lastname: Lange
authors.affiliation: Health Services Organisation unit, Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium.
authors.forename: B
authors.initials: B
authors.lastname: Marchal
authors.affiliation: Unit of Maternal and Reproductive Health, Public Health Department, Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium.
authors.forename: F
authors.initials: F
authors.lastname: Richard
mesh_terms: D000328:Adult; D001541:Benin; D002050:Burkina Faso; D016022:Case-Control Studies; D002585:Cesarean Section / Q000191:economics; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric / Q000191:economics* / Q000706:statistics & numerical data; D005260:Female; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006291:Health Policy / Q000191:economics*; D006297:Health Services Accessibility / Q000191:economics* / Q000706:statistics & numerical data; D006801:Humans; D007231:Infant, Newborn; D008302:Mali; D008427:Maternal Health Services / Q000191:economics* / Q000458:organization & administration; D009018:Morocco; D011247:Pregnancy
keywords: Benin; Burkina Faso; Caesareans; Deliveries; Exemptions; Mali; Maternal health; Morocco; User fees