Lagarde Mylene, Lépine Aurélia, Chansa Collins
Department of Health Policy, London School of Economics and Political Science, UK.
Institute for Global Health, University College London, UK.
SSM Popul Health. 2022 Feb 24;17:101051. doi: 10.1016/j.ssmph.2022.101051. eCollection 2022 Mar.
As women in many countries still fail to give birth in facilities due to financial barriers, many see the abolition of user fees as a key step on the path towards universal coverage. We exploited the staggered removal of user charges in Zambia from 2006 to estimate the effect of user fee removal up to five years after the policy change. We used data from the birth histories of two nationally representative Demographic and Health Surveys to implement a difference-in-differences analysis and identify the causal impact of removing user charges on institutional and assisted deliveries, caesarean sections and neonatal deaths. We also explored heterogeneous effects of the policy. Removing fees had little effect in the short term but large positive effects appeared about two years after the policy change. Institutional deliveries in treated areas increased by 10 and 15 percentage points in peri-urban and rural districts respectively (corresponding to a 25 and 35 percent change), driven entirely by a reduction in home births. However, there was no evidence that the reform changed the behaviours of women with lower education, the proportion of caesarean sections or reduced neonatal mortality. Institutional deliveries increased where care quality was high, but not where it was low. While abolishing user charges may reduce financial hardship from healthcare payments, it does not necessarily improve equitable access to care or health outcomes. Shifting away from user fees is a necessary but insufficient step towards universal health coverage, and concurrent reforms are needed to target vulnerable populations and improve quality of care.
由于经济障碍，许多国家的女性仍无法在医疗机构分娩，因此许多人将取消使用者付费视为实现全民覆盖道路上的关键一步。我们利用赞比亚在2006年逐步取消使用者付费的情况，来估计政策变化后长达五年取消使用者付费的影响。我们使用了两项具有全国代表性的人口与健康调查的生育史数据，进行了双重差分分析，以确定取消使用者付费对机构分娩和辅助分娩、剖腹产以及新生儿死亡的因果影响。我们还探讨了该政策的异质性影响。取消费用在短期内影响不大，但在政策变化约两年后出现了很大的积极影响。在政策实施地区，城市周边和农村地区的机构分娩分别增加了10个和15个百分点（分别相当于25%和35%的变化），这完全是由家庭分娩减少所推动的。然而，没有证据表明改革改变了受教育程度较低女性的行为、剖腹产比例或降低了新生儿死亡率。在医疗质量高的地方，机构分娩增加了，但在医疗质量低的地方则没有增加。虽然取消使用者付费可能会减轻医疗支付带来的经济困难，但不一定能改善获得医疗服务的公平性或健康结果。从使用者付费转向免费是朝着全民健康覆盖迈出的必要但不充分的一步，还需要同时进行改革，以针对弱势群体并提高医疗质量。
