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

Document Type : Original Article


1 Heidelberg Institute of Global Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany

2 Heidelberg Institute of Global Health and Division of Tropical Medicine, Medical Faculty, University of Heidelberg, Heidelberg, Germany

3 Health, Nutrition and Population Global Practice, World Bank, Washington, DC, USA

4 National Institute of Public Health, Ouagadougou, Burkina Faso

5 Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK


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.

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).

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.

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.


  1. Kieny MP, Bekedam H, Dovlo D, et al. Strengthening health systems for universal health coverage and sustainable development. Bull World Health Organ. 2017;95(7):537-539. doi:2471/blt.16.187476
  2. Carrin G, James C, Evans D. Achieving Universal Health Coverage: Developing the Health Financing System. Geneva: World Health Organization; 2005. Accessed December 11, 2020.
  3. Lagarde M, Palmer N. The impact of user fees on access to health services in low- and middle-income countries. Cochrane Database Syst Rev. 2011(4):CD009094. doi:1002/14651858.cd009094
  4. Ahinkorah BO, Ameyaw EK, Seidu AA, Odusina EK, Keetile M, Yaya S. Examining barriers to healthcare access and utilization of antenatal care services: evidence from demographic health surveys in sub-Saharan Africa. BMC Health Serv Res. 2021;21(1):125. doi:1186/s12913-021-06129-5
  5. Ahinkorah BO, Budu E, Seidu AA, et al. Barriers to healthcare access and healthcare seeking for childhood illnesses among childbearing women in sub-Saharan Africa: a multilevel modelling of Demographic and Health Surveys. PLoS One. 2021;16(2):e0244395. doi:1371/journal.pone.0244395
  6. Anderson GA, Ilcisin L, Kayima P, et al. Out-of-pocket payment for surgery in Uganda: the rate of impoverishing and catastrophic expenditure at a government hospital. PLoS One. 2017;12(10):e0187293. doi:1371/journal.pone.0187293
  7. Saksena P, Xu K, Durairaj V. The Drivers of Catastrophic Expenditure: Outpatient Services, Hospitalization or Medicines? World Health Report (2010) Background Paper, No 21. World Health Organization; 2010. Accessed June 10, 2020.
  8. Su TT, Kouyaté B, Flessa S. Catastrophic household expenditure for health care in a low-income society: a study from Nouna district, Burkina Faso. Bull World Health Organ. 2006;84(1):21-27. doi:2471/blt.05.023739
  9. Salari P, Di Giorgio L, Ilinca S, Chuma J. The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018. BMJ Glob Health. 2019;4(6):e001809. doi:1136/bmjgh-2019-001809
  10. Ministère de la Santé du Burkina Faso. Manual d’execution de la strategie nationale de subvention des accouchements et des soins obstétricaux et néonataux d’urgence au Burkina Faso (SONU); April 2006.
  11. Ridde V, Yaméogo P. How Burkina Faso used evidence in deciding to launch its policy of free healthcare for children under 5 and women in 2016. Palgrave Commun. 2018;4(1):119. doi:1057/s41599-018-0173-x
  12. Barroy H, André F, Nitiema A. Transition to Programme Budgeting in Health in Burkina Faso: Status of the Reform and Preliminary Lessons for Health Financing. World Health Organization; 2018. Accessed June 10, 2020.
  13. Seppey M, Ridde V, Somé PA. Scaling-up performance-based financing in Burkina Faso: from PBF to user fees exemption strategic purchasing. Int J Health Policy Manag. 2022;11(5):670-682. doi:34172/ijhpm.2020.209
  14. Zombré D, De Allegri M, Platt RW, Ridde V, Zinszer K. An evaluation of healthcare use and child morbidity 4 years after user fee removal in rural Burkina Faso. Matern Child Health J. 2019;23(6):777-786. doi:1007/s10995-018-02694-0
  15. Beaugé Y, De Allegri M, Ouédraogo S, Bonnet E, Kuunibe N, Ridde V. Do targeted user fee exemptions reach the ultra-poor and increase their healthcare utilisation? A panel study from Burkina Faso. Int J Environ Res Public Health. 2020;17(18):6543. doi:3390/ijerph17186543
  16. Druetz T, Bicaba A, Some T, Kouanda S, Ly A, Haddad S. Effect of interrupting free healthcare for children: Drawing lessons at the critical moment of national scale-up in Burkina Faso. Soc Sci Med. 2017;185:46-53. doi:1016/j.socscimed.2017.05.040
  17. Druetz T, Fregonese F, Bado A, et al. Abolishing fees at health centers in the context of community case management of malaria: what effects on treatment-seeking practices for febrile children in rural Burkina Faso? PLoS One. 2015;10(10):e0141306. doi:1371/journal.pone.0141306
  18. Ridde V, Agier I, Jahn A, et al. The impact of user fee removal policies on household out-of-pocket spending: evidence against the inverse equity hypothesis from a population based study in Burkina Faso. Eur J Health Econ. 2015;16(1):55-64. doi:1007/s10198-013-0553-5
  19. Abdou Illou MM, Haddad S, Agier I, Ridde V. The elimination of healthcare user fees for children under 5 substantially alleviates the burden on household expenses in Burkina Faso. BMC Health Serv Res. 2015;15:313. doi:1186/s12913-015-0957-2
  20. Ben Ameur A, Ridde V, Bado AR, Ingabire MG, Queuille L. User fee exemptions and excessive household spending for normal delivery in Burkina Faso: the need for careful implementation. BMC Health Serv Res. 2012;12:412. doi:1186/1472-6963-12-412
  21. Nguyen HT, Zombré D, Ridde V, De Allegri M. The impact of reducing and eliminating user fees on facility-based delivery: a controlled interrupted time series in Burkina Faso. Health Policy Plan. 2018;33(8):948-956. doi:1093/heapol/czy077
  22. Ridde V, Kouanda S, Yameogo M, Kadio K, Bado A. Why do women pay more than they should? A mixed methods study of the implementation gap in a policy to subsidize the costs of deliveries in Burkina Faso. Eval Program Plann. 2013;36(1):145-152. doi:1016/j.evalprogplan.2012.09.005
  23. Leone T, Cetorelli V, Neal S, Matthews Z. Financial accessibility and user fee reforms for maternal healthcare in 5 sub-Saharan countries: a quasi-experimental analysis. BMJ Open. 2016;6(1):e009692. doi:1136/bmjopen-2015-009692
  24. Philibert A, Ridde V, Bado A, Fournier P. No effect of user fee exemption on perceived quality of delivery care in Burkina Faso: a case-control study. BMC Health Serv Res. 2014;14:120. doi:1186/1472-6963-14-120
  25. Zombré D, De Allegri M, Ridde V. Immediate and sustained effects of user fee exemption on healthcare utilization among children under 5 in Burkina Faso: a controlled interrupted time-series analysis. Soc Sci Med. 2017;179:27-35. doi:1016/j.socscimed.2017.02.027
  26. De Allegri M, Lohmann J, Hillebrecht M, Brenner S, Koulidiati JL. Results-Based Financing for Health Impact Evaluation in Burkina Faso: Results Report. Vol 2. 2018.
  27. Beaugé Y, Ridde V, Bonnet E, Souleymane S, Kuunibe N, De Allegri M. Factors related to excessive out-of-pocket expenditures among the ultra-poor after discontinuity of PBF: a cross-sectional study in Burkina Faso. Health Econ Rev. 2020;10(1):36. doi:1186/s13561-020-00293-w
  28. De Allegri M, Lohmann J, Koulidiati JL, Somé PA. Qualitative Research to Explain and Unpack Quantitative Findings from the Performance-Based Financing Impact Evaluation in Burkina Faso: Results Report. 2019. Accessed January 25, 2022.
  29. Diaconu K, Falconer J, Verbel A, Fretheim A, Witter S. Paying for performance to improve the delivery of health interventions in low- and middle-income countries. Cochrane Database Syst Rev. 2021;5(5):CD007899. doi:1002/14651858.CD007899.pub3
  30. Turcotte-Tremblay AM, De Allegri M, Gali-Gali IA, Ridde V. The unintended consequences of combining equity measures with performance-based financing in Burkina Faso. Int J Equity Health. 2018;17(1):109. doi:1186/s12939-018-0780-6
  31. Kuunibe N, Lohmann J, Hillebrecht M, Nguyen HT, Tougri G, De Allegri M. What happens when performance-based financing meets free healthcare? Evidence from an interrupted time-series analysis. Health Policy Plan. 2020;35(8):906-917. doi:1093/heapol/czaa062
  32. Koulidiati JL, De Allegri M, Lohmann J, et al. Impact of Performance-Based Financing on effective coverage for curative child health services in Burkina Faso: evidence from a quasi-experimental design. Trop Med Int Health. 2021;26(8):1002-1013. doi:1111/tmi.13596
  33. Mwase T, Lohmann J, Hamadou S, et al. Can combining performance-based financing with equity measures result in greater equity in utilization of maternal care services? Evidence from Burkina Faso. Int J Health Policy Manag. 2022;11(3):308-322. doi:34172/ijhpm.2020.121
  34. Steenland M, Robyn PJ, Compaore P, et al. Performance-based financing to increase utilization of maternal health services: evidence from Burkina Faso. SSM Popul Health. 2017;3:179-184. doi:1016/j.ssmph.2017.01.001
  35. Meda IB, Baguiya A, Ridde V, Ouédraogo HG, Dumont A, Kouanda S. Out-of-pocket payments in the context of a free maternal health care policy in Burkina Faso: a national cross-sectional survey. Health Econ Rev. 2019;9(1):11. doi:1186/s13561-019-0228-8
  36. Kafando, Yamba, Kiendrébéogo JA, Tapsobaiii C, Metangmo P-M, Boxshall M. Briefing: the gratuité user fee replacement policy in Burkina Faso. ThinkWell. 2020. Accessed June 19, 2020.
  37. Boxshall M, Kiendrébéogo JA, Kafando Y, Tapsoba C, Straubinger S, Metangmo PM. An Overview of the User Fee Exemption Policy (Gratuité) in Burkina Faso. 2020. Accessed April 30, 2021.
  38. Sia D, Dondbzanga BDG, Carabali M, Bonnet E, Enok Bonong PR, Ridde V. Effect of a free healthcare policy on health services utilisation for non-malarial febrile illness by children under 5 years in Burkina Faso: an interrupted time series analysis. Trop Med Int Health. 2020;25(10):1226-1234. doi:1111/tmi.13468
  39. Ouédraogo M, Rouamba T, Samadoulougou S, Kirakoya-Samadoulougou F. Effect of free healthcare policy for children under 5 years old on the incidence of reported malaria cases in Burkina Faso by Bayesian modelling: "not only the ears but also the head of the hippopotamus.” Int J Environ Res Public Health. 2020;17(2):417. doi:3390/ijerph17020417
  40. Zombré DY, De Allegri M, Ridde V, Zinszer K. User fees removal and community-based management of undernutrition in Burkina Faso: what effects on children's nutritional status? Public Health Nutr. 2021;24(12):3768-3779. doi:1017/s1368980021000732
  41. Falisse JB, Ndayishimiye J, Kamenyero V, Bossuyt M. Performance-based financing in the context of selective free health-care: an evaluation of its effects on the use of primary health-care services in Burundi using routine data. Health Policy Plan. 2015;30(10):1251-1260. doi:1093/heapol/czu132
  42. Mathauer I, Mathivet B, Kutzin J. Free Health Care Policies: Opportunities and Risks for Moving Towards UHC. Geneva: World Health Organization. 2017. Accessed June 10, 2020.
  43. Nabyonga Orem J, Mugisha F, Kirunga C, Macq J, Criel B. Abolition of user fees: the Uganda paradox. Health Policy Plan. 2011;26 Suppl 2:ii41-51. doi:1093/heapol/czr065
  44. James CD, Hanson K, McPake B, et al. To retain or remove user fees? Appl Health Econ Health Policy. 2006;5(3):137-153. doi:2165/00148365-200605030-00001
  45. Asante F, Chikwama C, Daniels A, Armar-Klemesu M. Evaluating the economic outcomes of the policy of fee exemption for maternal delivery care in Ghana. Ghana Med J. 2007;41(3):110-117. doi:4314/gmj.v41i3.55277
  46. Dalinjong PA, Wang AY, Homer CSE. Has the free maternal health policy eliminated out of pocket payments for maternal health services? Views of women, health providers and insurance managers in Northern Ghana. PLoS One. 2018;13(2):e0184830. doi:1371/journal.pone.0184830
  47. Opwora A, Waweru E, Toda M, et al. Implementation of patient charges at primary care facilities in Kenya: implications of low adherence to user fee policy for users and facility revenue. Health Policy Plan. 2015;30(4):508-517. doi:1093/heapol/czu026
  48. Ministere de la Santé Brukina Faso. Plan National De Developpement Sanitaire 2011-2020. Published 2011.
  49. Ridde V, Yaogo M, Kafando Y, et al. A community-based targeting approach to exempt the worst-off from user fees in Burkina Faso. J Epidemiol Community Health. 2010;64(1):10-15. doi:1136/jech.2008.086793
  50. The World Bank. Burkina Faso. Data. Published 2019. Accessed March 24, 2021.
  51. The World Bank. Burkina Faso. Data. Published 2018. Accessed March 24, 2021.
  52. Ridde V. From institutionalization of user fees to their abolition in West Africa: a story of pilot projects and public policies. BMC Health Serv Res. 2015;15(Suppl 3):S6. doi:1186/1472-6963-15-s3-s6
  53. Ministry of Health Burkina Faso. Annual Statistical Yearbook 2017, Burkina Faso. Ministry of Health Burkina Faso; 2017.
  54. Ministère de la Santé Burkina Faso. Guide de Mise En Oeuvre Du FBR Dans Le Secteur de La Santé Au Burkina Faso. Ministère de la Santé Burkina Faso; 2013. Accessed June 17, 2021.
  55. De Allegri M, Lohmann J, Souares A, et al. Responding to policy makers' evaluation needs: combining experimental and quasi-experimental approaches to estimate the impact of performance based financing in Burkina Faso. BMC Health Serv Res. 2019;19(1):733. doi:1186/s12913-019-4558-3
  56. Burkina Faso: Strategic Purchasing Strategies and Early Results. Washington, DC: ThinkWell; 2020.
  57. Google Finance. USD/XOF Currency Exchange. Published 2021. Accessed May 21, 2021.
  58. Barber J, Thompson S. Multiple regression of cost data: use of generalised linear models. J Health Serv Res Policy. 2004;9(4):197-204. doi:1258/1355819042250249
  59. Malehi AS, Pourmotahari F, Angali KA. Statistical models for the analysis of skewed healthcare cost data: a simulation study. Health Econ Rev. 2015;5:11. doi:1186/s13561-015-0045-7
  60. Deb P, Norton EC. Modeling health care expenditures and use. Annu Rev Public Health. 2018;39:489-505. doi:1146/annurev-publhealth-040617-013517
  61. Jones AM. Models for Health Care. Oxford University Press; 2010. doi:1093/oxfordhb/9780195398649.013.0024
  62. Angrist JD, Pischke JS. Mostly Harmless Econometrics: An Empiricist's Companion. Princeton University Press; 2008.
  63. Kruk ME, Mbaruku G, Rockers PC, Galea S. User fee exemptions are not enough: out-of-pocket payments for 'free' delivery services in rural Tanzania. Trop Med Int Health. 2008;13(12):1442-1451. doi:1111/j.1365-3156.2008.02173.x
  64. Hangoma P, Robberstad B, Aakvik A. Does free public health care increase utilization and reduce spending? Heterogeneity and long term effects. World Dev. 2018;101:334-350. doi:1016/j.worlddev.2017.05.040
  65. Masiye F, Kaonga O, Kirigia JM. Does user fee removal policy provide financial protection from catastrophic health care payments? Evidence from Zambia. PLoS One. 2016;11(1):e0146508. doi:1371/journal.pone.0146508
  66. Nakovics MI, Brenner S, Bongololo G, et al. Determinants of healthcare seeking and out-of-pocket expenditures in a "free" healthcare system: evidence from rural Malawi. Health Econ Rev. 2020;10(1):14. doi:1186/s13561-020-00271-2
  67. Radovich E, Dennis ML, Barasa E, et al. Who pays and how much? A cross-sectional study of out-of-pocket payment for modern contraception in Kenya. BMJ Open. 2019;9(2):e022414. doi:1136/bmjopen-2018-022414
  68. Carroll C, Patterson M, Wood S, Booth A, Rick J, Balain S. A conceptual framework for implementation fidelity. Implement Sci. 2007;2:40. doi:1186/1748-5908-2-40
  69. World Health Organization. Global Health Expenditure Database. Published 2021. Accessed March 10, 2021.
  70. Storeng KT, Baggaley RF, Ganaba R, Ouattara F, Akoum MS, Filippi V. Paying the price: the cost and consequences of emergency obstetric care in Burkina Faso. Soc Sci Med. 2008;66(3):545-557. doi:1016/j.socscimed.2007.10.001
  71. Storeng KT, Murray SF, Akoum MS, Ouattara F, Filippi V. Beyond body counts: a qualitative study of lives and loss in Burkina Faso after 'near-miss' obstetric complications. Soc Sci Med. 2010;71(10):1749-1756. doi:1016/j.socscimed.2010.03.056
  72. Ridde V, Leppert G, Hien H, Robyn PJ, De Allegri M. Street-level workers' inadequate knowledge and application of exemption policies in Burkina Faso jeopardize the achievement of universal health coverage: evidence from a cross-sectional survey. Int J Equity Health. 2018;17(1):5. doi:1186/s12939-017-0717-5
  73. Chinkhumba J, De Allegri M, Mazalale J, et al. Household costs and time to seek care for pregnancy related complications: the role of results-based financing. PLoS One. 2017;12(9):e0182326. doi:1371/journal.pone.0182326
  74. Lee JS, Mogasale V, Lim JK, et al. A multi-country study of the economic burden of dengue fever based on patient-specific field surveys in Burkina Faso, Kenya, and Cambodia. PLoS Negl Trop Dis. 2019;13(2):e0007164. doi:1371/journal.pntd.0007164
  75. Castellani J, Mihaylova B, Siribié M, et al. Household costs and time to treatment for children with severe febrile illness in rural Burkina Faso: the role of rectal artesunate. Malar J. 2018;17(1):380. doi:1186/s12936-018-2526-8
  • Receive Date: 09 September 2021
  • Revise Date: 17 March 2022
  • Accept Date: 22 November 2022
  • First Publish Date: 23 November 2022