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Background To reduce financial barriers to access, and improve access to and use of skilled maternal and newborn healthcare services, the government of Ghana, in 2003, implemented a new maternal healthcare policy that provided free maternity care services in all public and mission healthcare facilities. Although supervised delivery in Ghana has increased from 47% in 2003 to 55% in 2010, strikingly high maternal mortality ratio and low percentage of skilled attendance are still recorded in many parts of the country. To explore health system factors that inhibit women’s access to and use of skilled maternal and newborn healthcare services in Ghana despite these services being provided free. Methods We conducted qualitative research with 185 expectant and lactating mothers and 20 healthcare providers in six communities in Ghana between November 2011 and May 2012. We used Attride-Stirling’s thematic network analysis framework to analyze and present our data. Results We found that in addition to limited and unequal distribution of skilled maternity care services, women’s experiences of intimidation in healthcare facilities, unfriendly healthcare providers, cultural insensitivity, long waiting time before care is received, limited birthing choices, poor care quality, lack of privacy at healthcare facilities, and difficulties relating to arranging suitable transportation were important health system barriers to increased and equitable access and use of services in Ghana. Conclusion Our findings highlight how a focus on patient-side factors can conceal the fact that many health systems and maternity healthcare facilities in low-income settings such as Ghana are still chronically under-resourced and incapable of effectively providing an acceptable minimum quality of care in the event of serious obstetric complications. Efforts to encourage continued use of maternity care services, especially skilled assistance at delivery, should focus on addressing those negative attributes of the healthcare system that discourage access and use.

In Burkina Faso, in July 2016, user fees were removed at all public healthcare facilities, but only for children under 60 months of age and for \"mothers\", i.e. for reproductive care. This study was conducted in five rural communities in Boulsa District (Burkina Faso) (1) to understand the perceptions and practices of stakeholders regarding compliance with eligibility criteria for free care and (2) to explore the ethical tensions that may have resulted from this policy. Semi-directed individual interviews (n = 20) were conducted with healthcare personnel and mothers of young children. Interviews were recorded and transcribed, and a thematic content analysis was conducted. The study reveals the presence of practices to circumvent strict compliance with the eligibility criteria for free access. These include hiding the exact age of children over 60 months and using eligible persons for the benefit of others. These practices result from ethical and economic tensions experienced by the beneficiaries. They also raise dilemmas among healthcare providers, who have to enforce compliance with the eligibility criteria while realizing the households' deprivation. Informal adjustments are introduced at the community level to reconcile the healthcare providers' dissonance. Local reinvention mechanisms help in overcoming ethical tensions and in implementing the policy.

This thematic study discusses strategies for sustainable financing of secondary education in Sub-Saharan Africa. The report provides insight into options for financing the expansion of secondary education and training in Africa. This comes with a hefty price tag and points to the need to undertake fundamental reforms swiftly. This publication messages are clear: secondary education and training in Sub-Saharan Africa faces the challenge of improved efficiency and improved quality simultaneously with a fast growing demand. Sustainable financing will also require more effective public-private partnerships, because governments have many priorities and do not have a lot of room for significant additional public funding of post-primary systems. Educational reforms are needed to expand enrollment in secondary schooling in affordable ways. These reforms will contribute to poverty reduction by increasing the levels of knowledge, skills, and capability; diminishing inequalities in access that limit social mobility and skew income distribution; and contributing to the achievement of the Millennium Development Goals (MDGs) that relate to education.

In Africa, user fees constitute a financial barrier to access to health services. Increasingly, international aid agencies are supporting countries that abolish such fees. However, African decision-makers want to know if eliminating payment for services is effective and how it can be implemented. For this reason, given the increase in experiences and the repeated requests from decisionmakers for current knowledge on this subject, we surveyed the literature. Using the scoping study method, 20 studies were selected and analysed. This survey shows that abolition of user fees had generally positive effects on the utilization of services, but at the same time, it highlights the importance of implementation processes and our considerable lack of knowledge on the matter at this time. We draw lessons from these experiences and suggest avenues for future research.

Introduction To reduce financial barriers to health care services presented by user fees, Burkina Faso adopted a policy to subsidize deliveries and emergency obstetric care for the period 2006-2015. Deliveries and caesarean sections are subsidized at 80%; women must pay the remainder. The worst-off are fully exempted. Methods The aim of this article is to document this policy's entire process using a health policy analytical framework. Qualitative data are drawn from individual interviews (n = 113 persons) and focus groups conducted with 344 persons in central government, three rural districts and one urban district. Quantitative data are taken from the national health information system in eight districts. Results The policy was initiated in all districts concurrently, before all the technical instruments were ready. The subsidy is paid by the national budget (US$60million, including US$10 million for the worst-off). Information activities, implementation and evaluation support have been minimal because of insufficient funding. Health workers and lay people have not always had the same information, such that the policy has not been uniformly applied. Coping strategies have been noted among health workers and the population, but there has been no attempt to impede the policy's implementation. At the time of the study, fixed-rate reimbursement for delivery (output-based) and overestimation of input costs were financially advantageous to health workers (bonuses) and management committees (hoarding). Very few of the worst-off have been exempted from payment because selection processes and criteria have not yet been defined and most health workers are unaware of this possibility. The upward trend in assisted deliveries since 2004 continued after the policy's introduction. Conclusions This ambitious policy expresses a strong political commitment but has not been adequately supported by international partners. Despite relatively tight administrative controls, health workers have figured out how to take advantage of the system. Some of the policy's instruments should be reviewed and clarified to improve its effectiveness.

Inadequate health financing is one of the major challenges health systems in low-income countries currently face. Health financing reforms are being implemented with an increasing interest in policies that abolish user fees. Data from three nationally representative surveys conducted in Uganda in 1999/ 2000, 2002/03 and 2005/06 were used to investigate the impact of user fee abolition on the attainment of universal coverage objectives. An increase in illness reporting was noted over the three surveys, especially among the poorer quintiles. An increase in utilization was registered in the period immediately following the abolition of user fees and was most pronounced in the poorest quintile. Overall, there was an increase in utilization in both public and private health care delivery sectors, but only at clinic and health centre level, not at hospitals. Our study shows important changes in health-care-seeking behaviour. In 2002/ 03, the poorest population quintile started using government health centres more often than private clinics whereas in 1999/2000 private clinics were the main source of health care. The richest quintile has increasingly used private clinics. Overall, it appears that the private sector remains a significant source of health care. Following abolition of user fees, we note an increase in the use of lower levels of care with subsequent reductions in use of hospitals. Total annual average expenditures on health per household remained fairly stable between the 1999/2000 and 2002/03 surveys. There was, however, an increase of US$21 in expenditure between the 2002/03 and 2005/06 surveys. Abolition of user fees improved access to health services and efficiency in utilization. On the negative side is the fact that financial protection is yet to be achieved. Out-of-pocket expenditure remains high and mainly affects the poorer population quintiles. A dual system seems to have emerged where wealthier population groups are switching to the private sector.

Background This study evaluated the effects on healthcare access inequities of an intervention exempting children under 5 years from user fees in Burkina Faso. Methods The design consisted of two complementary studies. The first was an interrupted time series (56 months before and 12 months after) study of daily curative consultations according to distance (<5, 5–9 and ≥10 km) in a stratified random sample of 18 health centres: 12 with the intervention and 6 without. The second was a household panel survey (n=1214) assessing the evolution of health-seeking behaviours. Multilevel regression was used throughout. Results Attendance doubled under the intervention, after adjusting for Centres de Santé et de Promotion Sociale size, districts, secular trend and seasonal variation. Utilisation increased for all distance ranges and in all of the 12 health centres of the intervention area. The exemption benefited all children (rate ratios (RR)=1.52 (1.23 to 1.88)), whether their health needs were high (RR=1.69 (1.22 to 2.32)) or not (RR=1.46 (1.10 to 1.93)) and whether the children lived near (RR=1.42 (1.09 to 1.85)) or far from a health centre (RR=1.79 (1.31 to 2.43)). The exemption benefited the children of poor families when health need was high and services near (RR=5.23; (1.30 to 20.99)). The amount saved for a child's treatment by the exemption was on average and median 2500 F CFA (≈US$5). Conclusions Exempting children under five from user fees is effective and helps reduce inequities of access. It benefits vulnerable populations, although their service utilisation remains constrained by limitations in geographic accessibility of services.

Objective: To document the effects of the abolition of user fees on utilization of health services in Uganda with emphasis on poor and vulnerable groups. Methods: A longitudinal study using quantitative and qualitative methods was carried out in 106 health facilities across the country. Health records were reviewed to determine trends in overall utilization patterns and use among vulnerable groups. A modification of wealth ranking as defined by the Uganda Poverty Participatory Assessment Project was used to categorize households by socio-economic status in order to compare utilization by the poor against that of other socio-economic groups. Findings: There was a marked increase in utilization in all population groups that was fluctuating in nature. The increase in utilization varied from 26% in public referral facilities in 2001, rising to 55% in 2002 compared with 2000. The corresponding figures for the lower level facilities were 44% and 77%, respectively. Increase in utilization among the poor was more than for other socio-economic categories. Women utilized health services more than men both before and after cost-sharing. Higher increases in utilization were noted among the over-five age group compared with the under-fives. There were no increases in utilization for preventive and inpatient services. With respect to quality of care, there were fewer drug stock-outs in 2002 compared with 2000 and 2001. There was no deterioration of other indicators such as cleanliness, compound maintenance and staff availability reported. Conclusion: The study suggests that there is a financial barrier created by cost-sharing that decreases access to services, especially among the poor in Uganda. However, further studies are needed to clarify issues of utilization by age and gender.

Background 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 challengeslinked to implementing exemption policies, we aimed to test the hypothesis that the user fee reductionpolicy had favoured the least poor more than the poor. Methods 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. Findings 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. Conclusions 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.

Objective To estimate how many child deaths might be prevented if user fees were removed in 20 African countries Design Simulation model combining evidence on key health interventions' impacts on reducing child mortality with analysis of the effect of fee abolition on access to healthcare services. Results Elimination of user fees could prevent approximately 233 000 (estimate range 153 000-305 000) deaths annually in children aged under 5 in 20 African countries. Conclusion Given the relatively low cost of abolition, replacing user fees with alternative financing mechanisms should be seen as an effective first step towards improving households' access to health care and achieving the millennium development goals for health.