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How Do User Fee Exemptions & Health Insurance Affect the Availability & Use of Maternal Health Care?

Expanding health insurance coverage and reducing or eliminating health care user fees both have been used in low- and middle-income countries to increase access to maternal health care.

But there is surprisingly little rigorous evidence evaluating how effective these approaches are.

Three Abt researchers were part of a group which reviewed existing literature as a follow-up to questions discussed at the 2012 U.S. Government Evidence Summit on Financial Incentives for Maternal Health. The researchers reported their findings in two journal articles at the request of USAID.

The first review examined the impact of policies which reduced or ended user fees - out-of-pocket fees charged in government health facilities. Such fees have previously been shown to limit poor women’s access to essential maternal health services. Nineteen studies examined user fee exemption policies since 1990.

“These policies do increase the use of certain maternal health services, especially giving birth in a health facility,” said Laurel Hatt, Ph.D., Abt Senior Associate and lead author of the article. However, Dr. Hatt said, the review also showed the research doesn’t provide very strong evidence for the impacts of these programs on health outcomes. User fee exemptions can also negatively affect the quality of health services, if health facility revenues decrease.

The second review examined twenty-nine articles focusing on the impact of health insurance on the use and quality of maternal health services as well as health outcomes. The lead author was Alison Comfort, Ph.D., an Associate at Abt, with Associate Analyst Lauren Peterson and Dr. Hatt as co-authors.

Similarly, the review found that enrollment in health insurance is correlated with increased use of priority services like delivery care and increased use of cesarean sections - the latter of which could have potentially negative consequences. But again more rigorous research is needed to better measure quality and assess impact on maternal health outcomes.

Dr. Hatt said the two reviews highlight the need for more rigorous evaluations of programs to increase access to care through health insurance and user fee exemptions, especially focusing on how to maintain the quality of care.

“Additional research is needed on how you best go about implementing these policies,” Dr. Hatt said.

Read the articles:
Effects of User Fee Exemptions on the Provision and Use of Maternal Health Services: A Review of Literature

Effect of Health Insurance on the Use and Provision of Maternal Health Services and Maternal and Neonatal Health Outcomes: A Systematic Review

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