Langlois Étienne V, Karp Igor, Serme Jean De Dieu, Bicaba Abel
Alliance for Health Policy and Systems Research, World Health Organization, Avenue Appia 20, 1211 Geneva, Switzerland,
Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Kresge Building, Room K201 London, Ontario N6A 5C1, Canada and.
Health Policy Plan. 2016 May;31(4):462-71. doi: 10.1093/heapol/czv088. Epub 2015 Oct 8.
In Sub-Saharan Africa, maternal and neonatal morbidity and mortality rates are associated with underutilization of skilled birth attendance (SBA). In 2007, Burkina Faso introduced a subsidy scheme for SBA fees. The objective of this study was to evaluate the effect of Burkina Faso's subsidy policy on SBA rate across socioeconomic status (SES) strata.
We used a quasi-experimental design. The data sources were two representative surveys (n = 1408 and n = 1403) of women from Houndé and Ziniaré health districts of Burkina Faso, and a survey of health centres assessing structural quality of care. Multilevel Poisson regression models were used with robust variance estimators. We estimated adjusted rate ratios (RR) and rate differences (RD) as a function of time and SES.
For lowest-SES women, immediately upon the introduction of the subsidy policy, the rate of SBA was 45% higher (RR = 1.45, 95% confidence interval (CI): 1.19-1.77) than expected in the absence of subsidy introduction. The results indicated a sustained effect after introduction of the subsidy policy, based on RR estimate (95% CI) of 1.48 (1.21-1.81) at 2 years. For middle-SES women, the RR estimates were 1.28 (1.09-1.49) immediately after introduction of the subsidy policy and 1.30 (1.11-1.51) at 2 years, respectively. For highest-SES women, the RR estimates were 1.19 (1.02-1.38) immediately after subsidy introduction and 1.21 (1.06-1.38) at 2 years, respectively. The RD (95% CI) was 14% (3-24%) for lowest-SES women immediately after introduction of the policy, and the effect was sustained at 14% (4-25%) at 2 years.
Our study suggests that the introduction of a user-fee subsidy in Burkina Faso resulted in increased rates of SBA across all SES strata. The increase was sustained over time and strongest among the poorest women. These findings have important implications for evidence-informed policy making in Burkina Faso and other countries in Sub-Saharan Africa.
在撒哈拉以南非洲地区，孕产妇和新生儿的发病率及死亡率与熟练接生服务（SBA）利用不足有关。2007年，布基纳法索推出了一项SBA费用补贴计划。本研究的目的是评估布基纳法索补贴政策对不同社会经济地位（SES）阶层SBA率的影响。
我们采用了准实验设计。数据来源为布基纳法索洪代和齐尼亚雷健康区对妇女进行的两项代表性调查（n = 1408和n = 1403），以及一项评估医疗结构质量的健康中心调查。使用具有稳健方差估计量的多水平泊松回归模型。我们估计了调整后的率比（RR）和率差（RD），作为时间和SES的函数。
对于SES最低的妇女，补贴政策一推出，SBA率比在未推出补贴时预期的高出45%（RR = 1.45，95%置信区间（CI）：1.19 - 1.77）。基于RR估计值（95% CI），补贴政策推出后2年的结果显示有持续影响，为1.48（1.21 - 1.81）。对于SES中等的妇女，补贴政策推出后RR估计值立即为1.28（1.09 - 1.49），2年后为1.30（1.11 - 1.51）。对于SES最高的妇女，补贴政策推出后RR估计值立即为1.19（1.02 - 1.38），2年后为1.21（1.06 - 1.38）。政策推出后，SES最低的妇女的RD（95% CI）立即为14%（3 - 24%），2年后该效应维持在14%（4 - 25%）。
我们的研究表明，布基纳法索引入用户费用补贴导致所有SES阶层的SBA率上升。这种上升随着时间持续，且在最贫困妇女中最为明显。这些发现对布基纳法索和撒哈拉以南非洲其他国家基于证据的政策制定具有重要意义。
