The long-term effects of free care on birth outcomes: Evidence from a national policy reform in Zambia

As women in many countries still fail to give birth in facilities due to financial barriers, many see the abolition of user fees as a key step on the path towards universal coverage. We exploited the staggered removal of user charges in Zambia from 2006 to estimate the effect of user fee removal over up to five years after the policy change. We used data from the birth histories of two nationally representative Demographic and Health Surveys to implement a difference-in-differences analysis and identify the causal impact of removing user charges on institutional and assisted deliveries, caesarean sections and neonatal deaths. We also used the rich survey data to explore heterogeneous effects of the policy. Removing fees had little effect in the short term but large positive effects appeared about two years after the policy change. Institutional deliveries in treated areas increased by 25 to 35%, driven entirely by a reduction in home births. However, there was no evidence that the reform changed the behaviours of women with lower education, the proportion of caesarean sections or reduced neonatal mortality. Institutional deliveries increased where care quality was high, but not where it was low. While abolishing user charges may reduce financial hardship from healthcare payments, it does not necessarily improve equitable access to care or health outcomes. Shifting away from user fees is a necessary but insufficient step towards universal health coverage, and concurrent reforms are needed to target vulnerable populations and improve quality of care.