Kerman University of Medical Sciences International Journal of Health Policy and Management 2322-5939 12 Issue 1 2023 12 01 To What Extent Do Free Healthcare Policies and Performance-Based Financing Reduce Out-of-Pocket Expenditures for Outpatient services? Evidence From a Quasi-experimental Study in Burkina Faso 1 11 4356 10.34172/ijhpm.2022.6767 EN Thit Thit Aye Heidelberg Institute of Global Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany Hoa Thi Nguyen Heidelberg Institute of Global Health and Division of Tropical Medicine, Medical Faculty, University of Heidelberg, Heidelberg, Germany Stephan Brenner Heidelberg Institute of Global Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany Paul Jacob Robyn Health, Nutrition and Population Global Practice, World Bank, Washington, DC, USA Ludovic Deo Gracias Tapsoba National Institute of Public Health, Ouagadougou, Burkina Faso Julia Lohmann Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK Heidelberg Institute of Global Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany Manuela De Allegri Heidelberg Institute of Global Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany Journal Article 2021 09 09 Background Burkina Faso has been implementing financing reforms towards universal health coverage (UHC) since 2006. Recently, the country introduced a performance-based financing (PBF) program as well as user fee removal (gratuité) policy for health services aimed at pregnant and lactating women and children under 5. We aim to assess the effect of gratuité and PBF policies on facility-based out-of-pocket expenditures (OOPEs) for outpatient services. Methods Our study is a controlled pre- and post-test design using healthcare facility data from the PBF program’s impact evaluation collected in 2014 and 2017. We compared OOPE related to primary healthcare use incurred by children under 5 and individuals above 5 to assess the effect of the gratuité policy on OOPE. We further compared OOPE incurred by individuals residing in PBF districts and non-PBF districts to estimate the effect of the PBF on OOPE. Effects were estimated using difference-in-differences models, distinguishing the estimation of the probability of incurring OOPE from the estimation of the magnitude of OOPE using a generalized linear model (GLM). Results The proportion of children under 5 incurring OOPE declined significantly from 90% in 2014 to 3% in 2017. Concurrently, mean OOPE also decreased. Differences in both the probability of incurring OOPE and mean OOPE between PBF and non-PBF facilities were small. Our difference in differences estimates indicated that gratuité produced an 84% (CI -86%, -81%) reduction in the probability of incurring OOPE and reduced total OOPE by 54% (CI 63%, 42%). We detected no significant effects of PBF, either in reducing the probability of incurring OOPE or in its magnitude. Conclusion User fee removal is an effective demand-side intervention for enhancing financial accessibility. As a supplyside intervention, PBF appears to have limited effects on reducing financial burden.

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