Removing user fees for facility-based delivery services: a difference-in-differences evaluation from ten sub-Saharan African countries

Background Several countries in sub-Saharan Africa have recently adopted policies that remove user fees for facility-based delivery services. There is little rigorous evidence of the impact of these policies on utilization of delivery services and no evaluations have examined effects on neonatal mortality rates (NMR). In this article, we estimate the causal effect of removing user fees on the proportion of births delivered in facilities, the proportion of births delivered by Caesarean section, and NMR. Methods We used data from Demographic and Health Surveys conducted in 10 African countries between 1997 and 2012. Kenya, Ghana and Senegal adopted policies removing user fees for facility-based deliveries between 2003 and 2007, while seven other countries not changing user fee policies were used as controls. We used a difference-in-differences (DD) regression approach to control for secular trends in the outcomes that are common across countries and for time invariant differences between countries. Results According to covariate-adjusted DD models, the policy change was consistent with an increase of 3.1 facility-based deliveries per 100 live births (95% confidence interval (CI): 0.9, 5.2) and an estimated reduction of 2.9 neonatal deaths per 1000 births (95% CI: -6.8, 1.0). In relative terms, this corresponds to a 5% increase in facility deliveries and a 9% reduction in NMR. There was no evidence of an increase in Caesarean deliveries. We examined lead and lag-time effects, finding evidence that facility deliveries continued to increase following fee removal. Conclusions Our findings suggest removing user fees increased facility-based deliveries and possibly contributed to a reduction in NMR. Evidence from this evaluation may be useful to governments weighing the potential benefits of removing user fees.