title: An assessment of the effect of user fee policy reform on facility-based deliveries in rural Zambia.
abstract: BACKGROUND
  Improving maternal health outcomes by reducing barriers to accessing maternal health services is a key goal for most developing countries. This paper analyses the effect of user fee removal, which was announced for rural areas of Zambia in April 2006, on the use of public health facilities for childbirth.
  
  
  METHODS
  Data from the 2007 Zambia Demographic and Health Survey, including birth histories for the five years preceding the survey, is linked to administrative data and geo-referenced health facility census data. We exploit a difference-in-differences design, due to a differential change in user fees at the district level; fees were removed in 54 rural districts, but not in the 18 remaining urban districts. We use multilevel modelling to estimate the effect of this policy change, based on 4018 births from May 2002 to September 2007, covering a period before and after the policy announcement in April 2006.
  
  
  RESULTS
  The difference-in-difference estimates point to statistically insignificant changes in the proportion of women giving birth at home and in public facilities, but significant changes are found for deliveries in private (faith-based) facilities. Thus, the abolition of delivery fees is found to have some effect on where Zambian mothers choose to have their children born.
  
  
  CONCLUSIONS
  The removal of user fees has not overcome barriers to the utilisation of delivery services at public facilities. User fee removal may also yield unintended consequences deterring the utilisation of delivery services. Therefore, abolishing user fees, alone, may not be sufficient to affect changes in utilisation; instead, other efforts, such as improving service quality, may have a greater impact.
authors.affiliation: Department of Economics, University of Zambia, Lusaka, Zambia. chitalu.chiliba@unza.zm.
authors.forename: Chitalu Miriam
authors.initials: CM
authors.lastname: Chama-Chiliba
authors.affiliation: Department of Economics, University of Pretoria, Pretoria, South Africa.
authors.forename: Steven Fredric
authors.initials: SF
authors.lastname: Koch
mesh_terms: D003695:Delivery of Health Care; D036861:Delivery, Obstetric / Q000191:economics; D005191:Family Characteristics; D005251:Fees, Medical; D005260:Female; D017048:Health Care Costs; D006268:Health Facilities; D006291:Health Policy; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D008427:Maternal Health Services / Q000191:economics* / Q000706:statistics & numerical data*; D036801:Parturition; D011247:Pregnancy; D012044:Regression Analysis; D012423:Rural Health; D012424:Rural Population; D015024:Zambia
keywords: Difference-in-differences; Facility-based deliveries; Maternal health; Rural; User fees; Zambia