Removing cost barriers — lessons from West Africa

June 10, 2016

Despite recent progress, as a region, sub-Saharan Africa has the highest rates of maternal, infant, and child mortality in the world. From 2009 to 2012, researchers led by Niger’s Laboratoire d'études et de recherches sur les dynamiques sociales et le développement local (LASDEL) analyzed government efforts in Burkina Faso, Mali, and Niger to increase access to health care by removing user fees.

In these three West African countries, nearly half the populations live in poverty, with women and children particularly at risk. Fees were removed or reduced for treatment and prevention of HIV/AIDS and malaria, caesarean sections and other deliveries, and care of pregnant women and children under five. In Niger, contraception and cancer treatment for women were also covered.

Research confirmed that removing financial barriers clearly increased access and use of health services among the poorest women, but found that poor planning and implementation threatened the quality of services provided. How the fee exemptions were introduced created new demands on already weak health systems. In Burkina Faso, for example, staff were inadequately prepared and complained of unmanageable workloads. Communities were poorly informed about the subsidies, and there were unclear boundaries between free services and those that were partly subsidized.

One of the biggest challenges in Niger, noted researcher Aïssa Diarra, were disruptions in medical supplies: “Funding is through a cost-recovery system. Institutions are repaid after the provision of service, but sometimes waited up to a year.”

The analysis suggests new policies and programs must reflect on-the-ground realities. Removal of user fees is not enough; governments need to put in place the organizational, technical, and financial mechanisms required to ensure the quality of primary health care is not undermined.

LASDEL is now leading a new five-year research and training effort that targets neglected problems within West African health systems. It will focus on sensitive areas crucial to maternal and child health, such as norms of practice among midwives, and the treatment of women who have experienced interrupted pregnancies. The aim is to inform public debate and mobilize policymakers, training institutions, and unions on systemic issues which stand in the way of healthcare reforms.

Learn more about IDRC-supported research on maternal health

"Funding is through a cost recovery system. Institutions are repaid after the provision of service, but sometimes waited up to a year."

Researcher Aïssa Diarra of Niger’s Laboratoire d'études et de recherches sur les dynamiques sociales et le développement local (LASDEL)