User fees exemptions alone are not enough to increase indigent use of healthcare services

The aim of this study was to assess whether user fees exemptions increased healthcare services use among indigents in the Ouargaye district in Burkina Faso. In this pre-post study, we surveyed 1224 indigents in 2010 about their healthcare services use over the preceding 6 months. Of these, 540 subsequently received a user fees exemption card. A follow-up survey was conducted 1 year later with a 55.3% retention rate. Analyses were performed in accordance with Andersen and Newman's model (Societal and individual determinants of medical care utilization in the United States. Milbank Q 1973;51:95-124) to explain healthcare services use by considering predisposing and facilitating factors and health needs indicators. Logistic regression analyses were performed.Among indigents exempted from user fees, 46.2% increased their healthcare services use in 2011, as opposed to 42.1% among the non-exempted. Being exempted was not associated with increased use of services (odds ratio, OR = 1.1, 95% confidence interval, CI [0.80-1.51]). Regardless of whether they were exempted or not, the indigents most likely to have increased their healthcare services use were older than 69 years of age (OR = 1.66, 95% CI [1.05-2.64]), male (OR = 1.44, 95% CI [0.99-2.08]), in low-income households (OR = 1.71, 95% CI [1.15-2.54]), and had received financial support from their families to obtain healthcare (OR = 1.59, 95% CI [1.1-2.28]). The indigents' increased healthcare services use was not attributable to user fees exemptions. Some contamination of the intervention is conceivable. Interventions combining user fees exemptions with actions targeting other obstacles to healthcare access would probably be more effective in increasing indigents' use of healthcare centres.