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,
Eur J Health Econ. 2015 Jan;16(1):55-64. doi: 10.1007/s10198-013-0553-5. Epub 2014 Jan 12.
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.
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.
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.
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.
用户付费取消政策在评估其对获得医疗服务的影响方面已经得到了广泛的研究，但在评估其对家庭自付（OOP）支出的影响方面却很少，而且大多数评估都做得很差。鉴于减少家庭经济负担是此类政策的明确目标，这种证据的缺乏令人惊讶。我们的研究评估了 2007 年以来布基纳法索实施的用户付费减免政策对医疗机构分娩的家庭 OOP 支出的公平影响（即，对所有人设定 900 非洲金融共同体法郎（CFA）的补贴价格，但对最贫困的人免费）。考虑到实施豁免政策所面临的挑战，我们旨在检验这样一个假设，即用户付费减免政策对最贫困的人比对贫困人口更为有利。
我们使用了在努纳卫生区进行的六轮连续家庭调查（2006-2011 年）的数据。主要结果是完全豁免的家庭比例（根据政策属于最贫困的 20%）和家庭在医疗机构分娩的实际 OOP 支出水平。效应的估计依赖于 Heckman 选择模型。这使我们能够根据政策产生的服务利用变化来估计不同社会经济阶层的 OOP 支出变化。
共有 2316 名妇女报告在 2006 年至 2011 年期间分娩。家庭 OOP 支出从 2006 年的 3827 非洲金融共同体法郎降至 2011 年的 1523 非洲金融共同体法郎，但在社会经济阶层之间没有显著差异，无论是在完全豁免付款的家庭数量方面，还是在支付金额方面。付款仍然是倒退的，大大高于规定的 900 非洲金融共同体法郎。
布基纳法索政策导致所有社会经济群体的家庭 OOP 健康支出显著且持续下降，但未能通过确保累进支付制度来妥善针对最贫困的人。
