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Objective To assess the evidence of the impact of user fees on maternal health service utilization and related health outcomes in low- and middle-income countries, as well as their impact on inequalities in these outcomes. Methods Studies were identified by modifying a search strategy from a related systematic review. Primary studies of any design were included if they reported the effect of fee changes on maternal health service utilization, related health outcomes and inequalities in these outcomes. For each study, data were systematically extracted and a quality assessment conducted. Due to the heterogeneity of study methods, results were examined narratively. Findings Twenty studies were included. Designs and analytic approaches comprised: two interrupted time series, eight repeated cross-sectional, nine before-and-after without comparison groups and one before-and-after in three groups. Overall, the quality of studies was poor. Few studies addressed potential sources of bias, such as secular trends over time, and even basic tests of statistical significance were often not reported. Consistency in the direction of effects provided some evidence of an increase in facility delivery in particular after fees were removed, as well as possible increases in the number of managed delivery complications. There was little evidence of the effect on health outcomes or inequality in accessing care and, where available, the direction of effect varied. Conclusion Despite the global momentum to abolish user fees for maternal and child health services, robust evidence quantifying impact remains scant. Improved methods for evaluating and reporting on these interventions are recommended, including better descriptions of the interventions and context, looking at a range of outcome measures, and adopting robust analytical methods that allow for adjustment of underlying and seasonal trends, reporting immediate as well as longer-term (e.g. at 6 months and 1 year) effects and using comparison groups where possible.

Lack of stable and dedicated funding has been a primary challenge for municipalities in the United States to implement effective stormwater management programs. Stormwater utility fees (SUFs), as user fees, are an alternative dedicated revenue source to fund stormwater management. When complemented with stormwater utility credits or discounts, SUFs provide greater flexibility to adopting best management practices and reducing stormwater runoff at a lower overall cost to the community. While SUFs have been increasingly used, there is little systematic research on this topic. This paper reviews literature on how SUFs work, discusses the mechanisms for setting the fees, and provides examples of different rate structures from across the U.S. Then, we use the findings of the literature to evaluate SUFs as a funding strategy for stormwater management based on four revenue evaluation criteria of efficiency, equity, revenue adequacy, and feasibility. Overall, the literature indicates that stormwater utility fees are a more efficient and environmentally sustainable source of revenue that allows for long-range planning of capital improvements and operations, but their high political visibility and legal obstacles can affect their effective implementation. However, more empirical research is needed to assess these propositions. There is a lack of literature on effective SUF designs, equitable fee types, the extent to which SUFs lead to change in public behavior and their impact on business and stormwater management investments in a municipality.

Background Over the past decade, an increasing number of low- and middle-income countries have reduced or removed user fees for pregnant women and/or children under five as a strategy to achieve universal health coverage. Despite the large number of studies (including meta-analyses and systematic reviews) that have shown this strategy’s positive effects impact on health-related indicators, the repercussions on women’s empowerment or gender equality has been overlooked in the literature. The aim of this study is to systematically review the evidence on the association between user fee policies in low- and middle-income countries and women’s empowerment. Methods A systematic scoping review was conducted. Two reviewers conducted the database search in six health-focused databases (Pubmed, CAB Abstracts, Embase, Medline, Global Health, EBM Reviews) using English key words. The database search was conducted on February 20, 2020, with no publication date limitation. Qualitative analysis of the included articles was conducted using a thematic analysis approach. The material was organized based on the Gender at Work analytical framework. Results Out of the 206 initial records, nine articles were included in the review. The study settings include three low-income countries (Burkina Faso, Mali, Sierra Leone) and two lower-middle countries (Kenya, India). Four of them examine a direct association between user fee policies and women’s empowerment, while the others address this issue indirectly —mostly by examining gender equality or women’s decision-making in the context of free healthcare. The evidence suggests that user fee removal contributes to improving women’s capability to make health decisions through different mechanisms, but that the impact is limited. In the context of free healthcare, women’s healthcare decision-making power remains undermined because of social norms that are prevalent in the household, the community and the healthcare centers. In addition, women continue to endure limited access to and control over resources (mainly education, information and economic resources). Conclusion User fee removal policies alone are not enough to improve women’s healthcare decision-making power. Comprehensive and multi-sectoral approaches are needed to bring sustainable change regarding women’s empowerment. A focus on “gender equitable access to healthcare” is needed to reconcile women’s empowerment and the efforts to achieve universal health coverage.

Realist reviews are a new form of knowledge synthesis aimed at providing middle-range theories (MRTs) that specify how interventions work, for which populations, and under what circumstances. This approach opens the ‘black box’ of an intervention by showing how it triggers mechanisms in specific contexts to produce outcomes. We conducted a realist review of health user fee exemption policies (UFEPs) in sub-Saharan Africa (SSA). This article presents how we developed both the intervention theory (IT) of UFEPs and a MRT of free public healthcare seeking in SSA, building on Sen’s capability approach. Over the course of this iterative process, we explored theoretical writings on healthcare access, services use, and healthcare seeking behaviour. We also analysed empirical studies on UFEPs and healthcare access in free care contexts. According to the IT, free care at the point of delivery is a resource allowing users to make choices about their use of public healthcare services, choices previously not generally available to them. Users’ ability to choose to seek free care is influenced by structural, local, and individual conversion factors. We tested this IT on 69 empirical studies selected on the basis of their scientific rigor and relevance to the theory. From that analysis, we formulated a MRT on seeking free public healthcare in SSA. It highlights three key mechanisms in users’ choice to seek free public healthcare: trust, risk awareness and acceptability. Contextual elements that influence both users’ability and choice to seek free care include: availability of and control over resources at the individual level; characteristics of users’ and providers’ communities at the local level; and health system organization, governance and policies at the structural level. Les revues réalistes sont une nouvelle forme de synthèse des connaissances visant à fournir des théories de portée intermédiaire (MRT) qui apportent des précisions sur le fonctionnement des interventions, ainsi que sur les populations ciblées et les conditions de leur mise en œuvre. Cette approche ouvre la «boîte noire» d’une intervention en montrant comment elle déclenche des mécanismes dans des contextes spécifiques afin de produire des résultats. Nous avons procédé à un examen réaliste des politiques d’exemption des frais d’utilisation des services de santé (UFEP) en Afrique subsaharienne (ASS). Le présent article présente la méthode utilisée pour élaborer en même temps la théorie de l’intervention (IT) des UFEP et une MRT de recherche des soins de santé gratuits en Afrique subsaharienne, en s’appuyant sur la notion des capacités de Sen. Au cours de ce processus itératif, nous avons exploré des écrits théoriques sur l’accès aux soins de santé, l’utilisation des services et la recherche des soins de santé. Nous avons également analysé des études empiriques sur les UFEP et l’accès aux soins de santé dans des contextes de soins gratuits. A en croire la théorie IT, les soins gratuits au point de livraison sont une ressource qui permet aux utilisateurs de procéder à des choix en ce qui concerne leur utilisation des services publics de soins de santé, des choix qui ne leur étaient pas proposés auparavant. La capacité des usagers à opter pour la recherche des soins gratuits est influencée par des facteurs de conversion structurels, locaux et individuels. Nous avons testé cette théorie de l’intervention sur 69 études empiriques sélectionnées en fonction de leur rigueur scientifique et de leur pertinence par rapport à la théorie. À partir de cette analyse, nous avons formulé une MRT sur la recherche des soins de santé gratuits en Afrique subsaharienne. Elle met en évidence trois mécanismes-clés qui amènent les usagers à rechercher des soins de santé gratuits: la confiance, la prise de conscience des risques et l’acceptabilité. Les éléments contextuels qui influencent la capacité des utilisateurs et le choix de rechercher des soins gratuits incluent: la disponibilité et le contrôle des ressources au niveau individuel; les caractéristiques des communautés d’utilisateurs et de prestataires au niveau local; l’organisation du système de santé, la gouvernance et les politiques au niveau structurel. 现实综述是一种新的知识整合形式, 旨在提供中层理论 （MRTs） 来阐述干预如何产生效果, 对什么人群有效, 以及在 何种情况下有效。这一方法展示了一种干预在特定条件下如 何触发机制、产生作用, 由此打开了”黑匣子”。我们对撒哈拉 以南非洲地区医疗用户费用豁免政策 （UFEPs） 进行了一项 现实综述。我们在Amartya Sen的能力方法基础上, 建立了 UFEPs的干预理论 （IT） 和撒哈拉以南非洲地区寻求免费公 共医疗的MRT。在迭代过程中, 我们查阅了关于医疗获取、 服务使用和求医行为的理论文章。我们还分析了在免费医疗 环境下UFEPs和医疗获取的实证研究。根据干预理论, 提供医 疗服务时免费允许用户对公共医疗服务做出选择, 而这种选择 过去通常是没有的。用户选择寻求免费医疗的能力受到结 构、本地和个体因素影响。为验证这一干预理论, 我们基于科 学严谨性和理论相关性选择了69个实证研究。在这一分析的 基础上, 我们形成了撒哈拉以南非洲地区寻求免费公共医疗的 MRT。该理论突出用户选择寻求免费公共医疗的3个关键机 制：信任、风险意识和接受度。影响用户能力和选择的环境 因素包括：个体可获得并掌握资源；本地用户和医疗提供者 群体的特征；以及结构水平的卫生体系组织、治理和政策。 Los análisis realistas son una nueva forma de síntesis del conocimiento dirigida a proporcionar teorías de rango medio (TRMs) que especifican cómo funcionan las intervenciones, para qué poblaciones y bajo qué circunstancias. Este enfoque abre la “caja negra” de una intervención mostrando cómo desencadena mecanismos en contextos específicos para producir resultados. Realizamos un análisis realista de las políticas de exención de cuotas al usuario de la salud (PECU) en el África sub-Sahariana (ASS). Este artículo explica como desarrollamos la teoría de la intervención (TI) de las PECUs y una TRM de la búsqueda de salud pública gratuita en el ASS, aprovechando el enfoque de la capacidad de Sen. A través de este proceso iterativo, exploramos escritos teóricos sobre el acceso a la atención de la salud, el uso de los servicios y el comportamiento de búsqueda de la atención de salud. También analizamos los estudios empíricos sobre las PECUs y el acceso a la asistencia de la salud en contextos de atención gratuita. De acuerdo con la TI, el cuidado gratuito en el punto de entrega es un recurso que permite a los usuarios tomar decisiones sobre el uso de los servicios públicos de salud, opciones que no estaban previamente disponibles para ellos. La capacidad de los usuarios para elegir y buscar atención gratuita está influenciada por factores de conversión estructurales, locales e individuales. Probamos esta TI en 69 estudios empíricos seleccionados sobre la base de su rigor científico y relevancia para la teoría. A partir de ese análisis, formulamos una TRM sobre la búsqueda de asistencia de salud gratuita en el ASS. Esto destaca tres mecanismos claves en la elección de los usuarios para buscar atención de salud pública gratuita: confianza, conciencia del riesgo y aceptabilidad. Los elementos contextuales que influyen tanto en la capacidad de los usuarios como en la opción de buscar atención gratuita incluyen: disponibilidad y control de los recursos a nivel individual; características de las comunidades de usuarios y proveedores a nivel local; y la organización, gobernanza y políticas del sistema de salud a nivel estructural.

User fee reduction and removal policies have been the object of extensive research, but little rigorous evidence exists on their sustained effects in relation to use of delivery care services, and no evidence exists on the effects of partial reduction compared with full removal of user fees. We aimed to fill these knowledge gaps by assessing sustained effects of both partial reduction and complete removal of user fees on utilization of facility-based delivery. Our study took place in four districts in the Sahel region of Burkina Faso, where the national user fee reduction policy (SONU) launched in 2007 (lowering fees at point of use by 80%) co-existed with a user fee removal pilot launched in 2008. We used Health Management Information System data to construct a controlled interrupted time-series analysis and examine both immediate and sustained effects of SONU and the pilot from January 2004 to December 2014. We found that both SONU and the pilot led to a sustained increase in the use of facility-based delivery. SONU produced an accumulative increase of 31.4% (P < 0.01) over 8 years in the four study districts. The pilot further enhanced utilization and produced an additional increase of 23.2% (P < 0.001) over 6 years. These increasing trends did not continue to reach full coverage, i.e. ensuring that all women had a facility-based delivery. Instead, they stabilized 3 years and 4 years after the onset of SONU and the pilot, respectively. Our study provides further evidence that user fee reduction and removal policies are effective in increasing service use in the long term. However, they alone are not sufficient to achieve full coverage. This calls for the need to implement additional measures, targeting for instance geographical barriers and knowledge gaps, to achieve the target of all women delivering in the presence of a skilled attendant. Les politiques de réduction et de suppression des frais d’utilisation ont fait l’objet de recherches approfondies, mais il existe peu de données rigoureuses sur leurs effets durables en termes d’utilisation des services obstétriques, et on ne dispose d’aucune donnée probante sur l’incidence de la réduction partielle par rapport à la suppression totale des frais d’accouchement. Nous avons cherché à combler ces lacunes en évaluant les effets durables de la réduction partielle et de la suppression totale des frais d’accouchement en milieu hospitalier. Notre étude a couvert quatre districts de la région du Sahel au Burkina Faso, dont la politique nationale de réduction des frais d’utilisation (SONU) lancée en 2007 (réduction de 80% des frais au point d’utilisation) a coexisté avec un projet pilote de suppression des frais d’utilisation initié en 2008. Nous avons utilisé les données du Système d’information sur la gestion de la santé pour élaborer une analyse contrôlée des séries chronologiques interrompues et examiner aussi bien les effets immédiats que durables de la SONU et du projet pilote de janvier 2004 a décembre 2014. Nous avons constaté que la SONU et le projet pilote ont entraîné un accroissement constant du nombre d’accouchements en milieu hospitalier. La SONU a permis une augmentation cumulée de 31,4 % (P<0,01) sur 8 ans dans les quatre districts étudiés. Le projet pilote a renforcé l’utilisation des services obstétricaux et entraîné une augmentation supplémentaire de 23,2 % (P<0,001) sur une période de six ans. Ces tendances à la hausse n’ont pas été assez soutenues pour permettre d’atteindre une couverture complète, en d’autres termes, permettre que toutes les femmes accouchent en milieu hospitalier. Par contre, elles se sont stabilisées, 3 et 4 ans respectivement, après le lancement de la SONU et du projet pilote. Notre étude fournit d’autres données tendant à prouver que les politiques de réduction et de suppression des frais d’utilisation sont efficaces dans l’optique d’une utilisation accrue des services à long terme. Cependant, ces deux facteurs ne suffisent pas, à eux seuls, à garantir une couverture complète. Il est donc nécessaire de mettre en œuvre des mesures supplémentaires, ciblant par exemple les obstacles géographiques et les lacunes en matière de connaissances, afin d’atteindre l’objectif d’amener toutes les femmes à accoucher sous le contrôle d’un personnel qualifié. Las políticas de reducción y eliminación de las cuotas del usuario han sido el objeto de investigación exhaustiva, pero poca evidencia rigurosa existe sobre sus efectos sostenidos en relación al uso de los servicios de parto, y no existe evidencia sobre los efectos de la reducción parcial comparada con la eliminación total de las cuotas del usuario. Tuvimos como objetivo llenar estas brechas en el conocimiento evaluando los efectos sostenido de la reducción parcial y la eliminación completa de las cuotas de usuario sobre la utilización de servicios de parto basados en los centros de salud. Nuestro estudio se llevó a cabo en cuatro distritos en la región Sahel de Burkina Faso, donde la política nacional de reducción de cuota de usuario (SONU) que fue lanzada en 2007 (reduciendo las cuotas para el usuario un 80%) coexistía con un programa piloto de eliminación de las cuotas de usuario que se lanzó en 2008. Usamos datos del Sistema de Información del Manejo de la Salud para construir un análisis de serie de tiempo interrumpida controlada y examinamos los efectos inmediatos y sostenidos de SONU y del programa piloto de enero de 2004 a diciembre de 2014. Encontramos que tanto SONU como el programa piloto condujeron a un aumento sostenido en el uso de los servicios de parto en los centros de salud. SONU produjo un aumento cumulativo de 31.4% (P<0.01) durante 8 años en los cuatro distritos del estudio. El programa piloto mejoró aún más la utilización y produjo un aumento adicional de 23.2% (P<0.01) durante 6 años. Este aumento en las tendencias no continuó hasta llegar a la cobertura total, o sea asegurando que todas las mujeres tuvieran un parto en un centro de salud. En cambio, se estabilizaron 3 y 4 años después del comienzo de SONU y el programa piloto, respectivamente. Nuestro estudio provee evidencia que las políticas de reducción y eliminación de las cuotas de usuario son efectivas en aumentar el uso de servicios a largo plazo. Sin embargo, por si solas no son suficientes para llegar a cobertura total. Esto muestra la necesidad de implementar medidas adicionales, por ejemplo, enfocándose en barreras geográficas y brechas del conocimiento, para lograr el objetivo de que todas las mujeres den a luz bajo la presencia de personal cualificado. 有大量研究探讨使用费减免政策, 但鲜有严格证据支持其对于 分娩服务的持续作用, 也没有证据比较减少使用费和免除使用 费的效果。本研究旨在填补这些研究空白, 评估减少和免除使 用费对住院分娩利用率的持续影响。研究地区是布基诺法索 Sahel的四个地区, 2007年开始实施国家使用费减少政策 （SONU）（实时减少80%费用）, 同时2008年启动了使用费 免除政策。我们使用卫生管理信息系统数据来进行对照中断 时间序列分析, 评估2004年1月至2014年12月SONU和试点项 目的即时和持续效果。结果显示, SONU和试点均使住院分娩 利用率持续增长。在四个研究地区, SONU在8年间产生的累 积增长率为31.4%（P<0.01）。试点项目在6年间使住院分娩 利用率进一步增加了23.2%（P<0.001）。上述增长趋势未达 到完全覆盖, 即所有妇女均住院分娩。增长趋势分别在SONU 和试点项目启动3年和4年后达到稳定。本研究进一步证明使 用费减免政策可长期促进卫生服务利用, 但不足以达到完全覆 盖。因此需要同时实施其他措施, 应对地理障碍和知识空缺等 因素, 实现所有妇女在熟练助产士辅助下分娩的目标。

Drawing upon archives in Malawi, the UK and the USA, this article explores the place of public-sector medicine in President Hastings Kamuzu Banda's ideology of social protection in post-colonial Malawi. In the midst of internecine strife with his cabinet soon after independence, Banda abandoned health-care user fees, provided free food to hospital inpatients and promised new medical facilities. Later, Banda disregarded international advisers by refusing to promote contraception. Though some commentators attributed this policy to Banda's conservatism, birth control also ran counter to his regime's carefully constructed symbolism of abundance. Malawi's government was not unique in opposing outside efforts at population control, but Banda's ideology, which invoked what anthropologists of the 1970s called 'wealth-in-people', made mass sterilisation and intrauterine device (IUD) campaigns particularly unacceptable. Banda also made grand displays of his government's new hospitals. While he would not devote significant domestic resources to health, he mobilised funds from external donors, particularly governments facing their own crises of legitimacy. This article, then, complicates the existing literature on health in Kamuzu Banda's Malawi. While Banda did not consider health a priority, his reliance on symbols of abundance, health and fertility left him vulnerable to critique and compelled him to direct a modicum of resources toward public sector health facilities and to keep care at those facilities free of charge.

Background User fees are a major barrier to accessing healthcare for children, especially in low- and middle-income countries. Policymakers have adopted free care policies to improve utilization and health outcomes, yet evidence specific to children remains fragmented. This systematic review synthesizes the impact of removing user fees on child health. Methods Following PRISMA guidelines, we searched PubMed, Scopus, and Web of Science for English-language studies published between January 1, 2010, and July 31, 2025. Studies were eligible if they assessed complete user fee removal for children (< 18 years), used experimental or quasi-experimental designs with control or pre–post comparisons, and reported at least one objective outcome on healthcare utilization, costs, or health status. Quality was appraised using the Joanna Briggs Institute checklist. Due to heterogeneity, findings were narratively synthesized by outcome category. Results Of 6,733 records identified, 38 studies from 16 countries were included, mostly from low-income African settings and targeting children under six. Most policies covered free outpatient primary care. Utilization increased in nearly all studies assessing outpatient visits (26/27) and in most inpatient service assessments. General health improvements included reduced anemia, fewer illness days, and better nutritional indicators. Child mortality declined in most studies, with reductions up to 92% for malaria-specific deaths. Financial protection improved in 12 studies, often with > 50% reductions in out-of-pocket payments. Equity effects were mixed, though several studies reported narrowing income-related gaps. Conclusions Removing user fees for children is generally associated with improvements in access, health outcomes, and financial protection and, in some contexts, greater equity. However, the magnitude and sustainability of these benefits depend on health system readiness, predictable financing, and efforts to address non-financial barriers such as transportation and service quality. Without parallel investments in infrastructure, workforce, and supply chains, free care policies risk overburdening facilities and undermining quality. When integrated into broader universal health coverage strategies, user fee removal can be a powerful tool for improving child health and reducing inequalities.

The aim of this study was to assess whether user fees exemptions increased healthcare services use among indigents in the Ouargaye district in Burkina Faso. In this pre–post study, we surveyed 1224 indigents in 2010 about their healthcare services use over the preceding 6 months. Of these, 540 subsequently received a user fees exemption card. A follow-up survey was conducted 1 year later with a 55.3% retention rate. Analyses were performed in accordance with Andersen and Newman’s model (Societal and individual determinants of medical care utilization in the United States. Milbank Q 1973;51:95–124) to explain healthcare services use by considering predisposing and facilitating factors and health needs indicators. Logistic regression analyses were performed. Among indigents exempted from user fees, 46.2% increased their healthcare services use in 2011, as opposed to 42.1% among the non-exempted. Being exempted was not associated with increased use of services (odds ratio, OR = 1.1, 95% confidence interval, CI [0.80–1.51]). Regardless of whether they were exempted or not, the indigents most likely to have increased their healthcare services use were older than 69 years of age (OR = 1.66, 95% CI [1.05–2.64]), male (OR = 1.44, 95% CI [0.99–2.08]), in low-income households (OR = 1.71, 95% CI [1.15–2.54]), and had received financial support from their families to obtain healthcare (OR = 1.59, 95% CI [1.1–2.28]). The indigents’ increased healthcare services use was not attributable to user fees exemptions. Some contamination of the intervention is conceivable. Interventions combining user fees exemptions with actions targeting other obstacles to healthcare access would probably be more effective in increasing indigents ’use of healthcare centres. L’objectif de cette étude était de mesurer l’impact des exonérations de cotisations pour les usagers sur une meilleure utilisation des services de soins pour les indigents dans le quartier Ouargave au Burkina Faso. Dans l’étude avant-après, nous avons enquêté au cours de l’année 2010 auprès de 1224 indigents sur leur utilisation des services de soins durant les 6 mois précédents. Sur ce nombre, 540 personnes ont reçu après-coup une carte d’exonération de cotisations. Une enquête de suivi a été réalisée un an plus tard, avec un taux de rétention de 55.3%. Les analyses effectuées suivaient le modèle Andersen et Newman (determinants sociétal et individuel de l’utilisation des structures de soins aux Etats Unis, Milbank Q 1973 51:95–124) pour expliquer le recours aux structures de soins, en tenant compte des facteurs de prédisposition et d’encouragement, ainsi que des indicateurs de besoins sanitaires. Des analyses de régression logistique ont été réalisées. Parmi les indigents exonérés de cotisations, 46.2% avaient accru leur recours aux structures de soins en 2011, contre 42.1% parmi les non exonérés. L’exonération de cotisations n’était pas associée à une plus grande utilisation des services de soins (taux de probabilité, OR=1.1, 95% d’intervalle de confiance, CI [0.80–1.51]). Qu’ils aient ou non bénéficié d’exonération de cotisations, les indigents qui étaient le plus à même d’avoir eu recours aux structures de soins étaient âgés de plus de 69 ans OR=1.66, 95% CI [1.05–2.64]), de sexe masculin (OR=1.44, 95% CI [0.99–2.08]), issus de ménages a faible revenu (OR=1.71, 95% CI [1.15–2.54]), et avaient reçu une aide financière de leur famille pour se faire soigner (OR=1.59, 95% CI [1.1–2.28]). Un meilleur accès aux structures de soins pour les indigents ne pouvait pas être attribué aux exonérations de cotisations. Il peut y avoir une pollution par l’ingérence. Les interventions combinant les exonérations de cotisations pour les usagers avec des actions visant à éliminer d’autres obstacles à l’accès aux soins serait probablement plus efficace et permettrait probablement aux indigents de recourir plus aisément aux structures de santé. El objetivo de este estudio fue evaluar si las exenciones de las tarifas al usuario incrementaron el uso de los servicios del cuidado de la salud entre los indigentes en el distrito Ouargaye en Burkina Faso. En este estudio pre-post, encuestamos 1.224 indigentes en 2010 sobre el uso del servicio del cuidado de la salud durante los 6 meses anteriores. De estos, 540 recibieron posteriormente la tarjeta de exención de las tarifas al usuario. Una encuesta de seguimiento se llevó a cabo 1 año más tarde, con una tasa de retención de 55.3%. Los análisis se realizaron de acuerdo con el modelo Andersen y Newman (Determinantes sociales e individuales de la utilización del cuidado médico en los Estados Unidos. Milbank Q 1973; 51:95-124) para explicar el uso de los servicios del cuidado de la salud, considerando los factores que predisponen y facilitan y los indicadores de necesidad de la salud. Se realizó análisis de regresión logística. Entre los indigentes exentos de tarifas a los usuarios, el 46.2% aumentó el uso de los servicios del cuidado de la salud en 2011, en comparación con el 42.1% entre los no exentos. El estar exento no se asoció con un mayor uso de los servicios (Razón de Probabilidad, RP=1.1, 95% intervalo de confianza CI [0.80-1.51]). Independientemente de si estaban o no exentos, los indigentes que más habían aumentado el uso de los servicios de salud fueron los mayores de 69 años de edad (RP=1.66, 95% CI[1.05-2.64]), los hombres (RP=1.44, 95% CI [0.99-2.08]), aquellos en los hogares de bajos ingresos (RP=1.71, 95% CI [1.15-2.54]), y aquellos que habían recibido apoyo financiero de sus familias para obtener el cuidado de la salud (PR=1.59, 95% CI [1.1- 2.28]). El incremento del uso de los servicios del cuidado de la salud de los indigentes no fue atribuible a las exenciones de las tarifas a los usuarios. Alguna contaminación de la intervención es concebible. Las intervenciones que combinan las exenciones de las tarifas al usuario, con acciones dirigidas a otros obstáculos para el acceso al cuidado de la salud, probablemente serían más efectivas en incrementar el uso de los centros de salud por parte de los indigentes. 本研究的目的是评估用户费豁免是否增加布基纳法索的瓦尔 加伊区穷人对医疗服务的使用。在这前期和后期研究中,我们 先在 2010 年调查了 1224 名穷人在过去 6 个月的医疗服务使 用情况。其中,540人随后收到了用户费豁免卡。1 年后进行 了后续调查, 用户费豁免卡的保留率为55.3% 。分析按照安德 森和纽曼的模型（美国医疗保健使用的社会和个人决定因素, MilbankQ1973;51:95–124）, 通过考虑诱发、促进因素和健 康需求指标来解释医疗服务的使用情况, 进行逻辑回归分析。 2011 年, 在免除用户费的穷人中, 46.2% 增加了他们的医疗服 务使用, 相对的, 在未免除用户费的穷人中增加了42.1% 。免 除费用与增加服务使用无关（比值比OR=1.1,95% 的置信区 间CI为[0.80–1.51]） 。不管他们是否被免除用户费,最可能 增加医疗服务使用的穷人是低收入家庭(OR=1.71,95%CI [1.15–2.54])中年龄超过69 岁(OR=1.66,95%CI[1.05–2.64]),并且经收到来自家人的医疗保健财务支持(OR= 1.59,95%CI[1.1–2.28])的男性(OR=1.44,95%CI[0.99–2.08])。穷人们增加医疗服务的使用是不归因于用户费豁免。 一些干预的污染是可以想象的。结合了用户费豁免与针对其 他医疗使用障碍的行动的干预措施可能会更有效地增加穷人 使用医疗保健中心。

Access to appropriate and affordable healthcare is needed to achieve better health outcomes in Africa. However, access to healthcare remains low, especially among the poor. In Zambia, poor access exists despite the policy by the government to remove user fees in all primary healthcare facilities in the public sector. The paper has two main objectives: (i) to examine the factors associated with healthcare choices among sick people, and (ii) to assess the determinants of the magnitude of out-of-pocket (OOP) payments related to a visit to a health provider. This paper employs a multilevel multinomial logistic regression to model the determinants of an individual's choice of healthcare options following an illness. Further, the study analyses the drivers of the magnitude of OOP expenditure related to a visit to a health provider using a two-part generalised linear model. The analysis is based on a nationally representative healthcare utilisation and expenditure survey that was conducted in 2014. Household per capita consumption expenditure is significantly associated with increased odds of seeking formal care (odds ratio [OR] = 1.12, P = .000). Living in a household in which the head has a higher level of education is associated with increased odds of seeking formal healthcare (OR = 1.54, P = .000) and (OR = 1.55, P = .01), for secondary and tertiary education, respectively. Rural residence is associated with reduced odds of seeking formal care (OR = 0.706, P = .002). The magnitude of OOP expenditure during a visit is significantly dependent on household economic well-being, distance from a health facility, among other factors. A 10% increase in per capita consumption expenditure was associated with a 0.2% increase in OOP health expenditure while every kilometre travelled was associated with a K0.51 increase in OOP health expenditure. Despite the removal of user fees on public primary healthcare in Zambia, access to healthcare is highly dependent on an individual's socio-economic status, illness type and region of residence. These findings also suggest that the benefits of free public healthcare may not reach the poorest proportionately, which raise implications for increasing access in Zambia and other countries in sub-Saharan Africa.

Evidence shows that user fee exemption policies improve the use of maternal, newborn, and child health (MNCH) services. However, addressing the cost of care is only one barrier to accessing MNCH services. Poor geographic accessibility relating to distance is another. Our objective in this study was to assess the effect of a user fee exemption policy in Burkina Faso (Gratuité) on antenatal care (ANC) use, considering distance to health facilities. We conducted a cross-sectional study with sub-analysis by intervention period to compare utilization of ANC services (outcome of interest) in pregnant women who used the service in the context of the Gratuité user fee exemption policy and those who did not, in Manga district, Burkina Faso. Dependent variables included were socio-demographic characteristics, obstetric history, and distance to the lower-level health facility (known as Centre de Santé et Promotion Sociale) in which care was sort. Univariate, bivariate, and multivariate analyses were performed across the entire population, within those who used ANC before the policy and after its inception. For women who used services before the Gratuité policy was introduced, those living 5-9 km were almost twice (OR = 1.94; 95% CI: 1.17-3.21) more likely to have their first ANC visit (ANC1) in the first trimester compared to those living <5 km of the nearest health facility. After the policy was introduced, women living 5-9 km and >10 km from the nearest facility were almost twice (OR = 1.86; 95% CI: 1.14-3.05) and over twice (OR = 2.04; 95% CI: 1.20-3.48) more likely respectively to use ANC1 in the first trimester compared to those living within 5 km of the nearest health facility. Also, women living over 10 km from the nearest facility were 1.29 times (OR = 1.29; 95% CI: 1.00-1.66) more likely to have 4+ ANC than those living less than 5 km from the nearest health facility. Insofar as the financial barrier to ANC has been lifted and the geographical barrier reduced for the populations that live farther away from services through the Gratuité policy, then the Burkinabé government must make efforts to sustain the policy and ensure that benefits of the policy reach the targeted and its gains maximized.