User Fees and Co-Payments: the Evidence Accumulates

Burkina Faso removed user fees for health care for children under five and for maternity care in 2008. Johri and colleagues [1] evaluated the effect on uptake of services (coverage), and then modelled the expected gains in mortality contingent on improved coverage using a tool called the “Lives Saved Tool”.[2] Service uptake increased nearly two-fold following the elimination of user fees. There was a substantial increase in use of potentially life-saving treatments. Sensitivity analyses took into account uncertainty in the data. It was estimated that the contingent reduction in child mortality would amount to 11% of all deaths, thanks to care made available to children with pneumonia, diarrhoea, malaria, and neonatal illnesses. Quantity of prescriptions was used as a proxy for quality of care and no deterioration was noted in the post-intervention period, thereby mitigating concern that safety would suffer as a result of increased clinical workloads. Abolishing user fees is particularly advantageous for very poor families; that is to say it improves equity of outcome.

— Richard Lilford, CLAHRC WM Director


  1. Johri M, Riddle V, Heinmüller R, Haddad S. Estimation of maternal and child mortality one year after use-fee elimination: an impact evaluation and modelling study in Burkina Faso. Bull World Health Organ. 2014; 92: 706-15.
  2. Winfrey W, McKinnon R, Stober J. Methods used in the Lives Saved Tool (LisT). BMC Public Health. 2011; 11(s3):s32.

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