We estimated the number of deaths in children aged under 5 years that could be prevented through abolition of user fees by combining evidence on the impact that key health interventions have in reducing child mortality2,3
with analysis of the potential of such abolition to increase the proportion of the population benefiting from these interventions. This analysis can only give a first estimate of the likely impact of abolition of fees, as the context of individual countries will determine the exact nature of the changes seen.
Our approach can be summarised as follows (see appendix on bmj.com
for full details). In a first stage, we developed a classification system for key interventions to improve child survival. This classified 26 interventions according to whether their use is expected to increase after abolition of fees and if so by how much (). We based this grouping primarily on the expected magnitude of price reduction after fee abolition, but it also incorporates effects on health promotion. The classification is based on representative prices across the region, rather than exact figures from any one country. However, in some countries (or regions within countries) a flat rate fee may be charged, at least in principle. We therefore also did a sensitivity analysis to reflect this situation. Importantly, the model assumes improvements in access after removal of fees, even if countries have waiver or exemption mechanisms for children under 5 and pregnant women (as is the case, for example, in Tanzania), as widespread evidence shows that these have generally been ineffective.4,5
Expected positive effects of abolition of user fees on access to key child health interventions
In the second stage of model development, we combined this intervention classification system with evidence from Uganda, South Africa, Madagascar, and Kenya on more generalised changes in use of health services after fee abolition,3,6-10
to produce estimates of expected changes in utilisation rate for each of the 26 interventions (). We did this by adjusting the generalised utilisation changes from these four countries downwards or upwards, according to each intervention's classification. We explored two basic scenarios: the Ugandan experience (analysed separately because of its more detailed data) and other post-fee abolition studies. For both, we also estimated expected higher increases in utilisation by poor people—poor (and near poor) people have typically been the most responsive to price changes and have higher rates of illness11-13
—giving four scenarios in total.
Estimated changes in utilisation rate (URΔ) after abolition of user fees, based on experience in four countries. Values are percentages
In a third stage, we converted these estimated increases in use of different health interventions into plausible reductions in mortality in children under 5. We did this by inputting estimates of expected proportional increases in the coverage of each intervention from 2003 levels into the updated Bellagio child survival impact model. This model estimates effects on child mortality by bringing together estimates of mortality in under 5s by country and cause, national coverage data for all interventions of proved efficacy, and estimates of cause specific efficacy for each intervention.2,3
We restricted the analysis to the 20 African countries with more than 50 000 child deaths annually and with user fees in place as of 2003. The model assumed that increased contacts with health facilities occur when a child is sick and at risk of dying, a seemingly plausible assumption given that travel and other non-healthcare costs will remain even after abolition of fees.