Establishing the impact, the cost-effectiveness and the benefit incidence of national user fee exemption policies in Africa: A multi-method study in Burkina Faso

• Applicant: Professorin Dr. Manuela De Allegri, Ph.D.
• Subject Area: Public Health, Healthcare Research, Social and Occupational Medicine
• Term: since 2016
• Project identifier: Deutsche Forschungsgemeinschaft (DFG) - Project number 289993500

This proposal builds on prior DFG-funded research to assess the effectiveness and the cost-effectiveness of a partial user fee exemption policy and a complete user fee exemption pilot, both targeting institutional delivery, implemented in Burkina Faso between 2007 and 2015. Our prior work demonstrates both the ability of the two programs to significantly increase health service utilization and their cost-effectiveness, judged both against the WHO and the country-level cost-effectiveness thresholds. To date, our work remains one of a handful of studies examining the cost-effectiveness of complex health financing interventions and the only one modelling the interventions’ impact to take into account both mortality and morbidity gains. Motivated by the urge to achieve the health-related Sustainable Development Goals, many countries are moving away from partial exemption policies and pilot experiences towards more comprehensive exemption policies implemented at national level. Scientific evidence on these national policies is largely lacking, especially when it comes to assessing their equity impact, their cost-effectiveness in relation to their equity impact, and the distributional incidence of the investments made to sustain them. The implementation of the 2016 national free health care policy for women and children under five in Burkina Faso, the gratuité, offers a unique opportunity to close existing evidence gaps. In this proposal, we expand the scope of our prior work and pursue three research objectives: 1. to determine the short- and the long-term impact of the gratuité on health service utilization and health outcomes; 2. to establish the cost-effectiveness and the extended cost-effectiveness of the gratuité in comparison to status quo service provision subject to payment of user charges; 3. to assess the distributional incidence of both total and public health spending within the framework of the gratuité. Our work adopts a multi-method approach and is organized around three study components, each reflecting one objective and endorsing an own set of outcome measures. A focus on equity permeates our work, with pertinent analyses being integrated within each study component. Our analytical approaches include Interrupted Time Series Analysis, Cost-effectiveness and Extended Cost-Effectiveness Analysis, and Benefit Incidence Analysis. We rely primarily on existing data sources (Health Management Information System data, Health and Demographic Surveillance data, National Health Accounts, own micro-costing service delivery study, and an own population-based survey) complemented with primary data derived from a retrospective facility-based survey and a central-level costing study. In light of our comprehensive and sound analytical framework, our work makes a substantial contribution both to the academic literature and the policy discourse on user fee exemption policies, and more broadly on healthcare financing, in sub-Saharan Africa.

• DFG Programme: Research Grants
• International Connection: Burkina Faso
• International Co-Applicant: Dr. Ali Sié, Ph.D.