From fees to free: User fee removal, maternal health care utilization and child health in Zambia

Despite recent progress, about 295,000 women in the World still die each year from pregnancy-related causes, and about 4.1 million children die before reaching the age of one. 99% of these deaths occur in developing countries. In 2006 the Zambian government removed user fees in public and mission health facilities in 54 out of 72 districts, and then extended this policy to rural parts of unaffected districts in 2007. I exploit the staggered implementation of the policy to assess its impact on maternal health care utilization and child health outcomes. Using a difference-in-differences estimation strategy, I find a 43% increase in the probability to give birth in a medical facility following the removal and a 36% increase in the probability of being assisted by a skilled birth attendant during childbirth. These positive effects decrease with household’s distance from the nearest health facility. In terms of child health, chronic malnutrition decreased by 8% and the abolition of user fees reduced newborn mortality risk only for those living close to a health facility providing essential emergency obstetric care and child health services. Access improved but returns to formal health services remained rather limited, highlighting the importance of addressing supply-side constraints to generate substantial gains in population health.