Since the 1980s in West Africa, women have had to pay for antenatal care consultations and deliveries. This system, known as user fees, imposes financial barriers for poor households. Evidence shows that deliveries in a health care centre with qualified staff reduces maternal and infant mortality.

In this paper, the authors investigate the agenda-setting criteria used by policy entrepreneurs directly involved in the implementation of user-fee abolition and reduction policies for maternal care in West Africa. They use a method called best-worst scaling to innovatively collect respondents’ answers to determine the most and least relevant criteria considered when making decisions about these policies. The results suggest that political commitment and impact on health are the most important factors leading to these decisions, while international pressure and donor money are rarely considered. The authors conclude their findings with two strategies: policy implementation must be mediated by equity considerations, and policy decisions must be accompanied by adequate implementation measures and must receive necessary funding.

Part of Series

The Africa Initiative Discussion Paper Series presents policy-relevant, peer-reviewed, field-based research that addresses substantive issues in the areas of conflict resolution, energy, food security, health, migration and climate change. The aim of the series is to promote discussion and advance knowledge on issues relevant to policy makers and opinion leaders in Africa. Papers in this series are written by experienced African and Canadian researchers, and have gone through the grant review process, or, in select cases, are commissioned studies supported by the Africa Initiative research program.
  • A. Torbica is assistant professor in the Department for Policy Analysis and Public Management, Centre for Research in Health and Social Care Management, Bocconi University, Italy.

  • M. De Allegri is research group leader in health economics and health financing at the Institute of Public Health, University of Heidelberg, Germany.

  • D. Yugbare Belemsaga is a health economist at the Institut de recherche en sciences de la santé, Burkina Faso.

  • A. Medina-Lara is senior lecturer in health economics at Peninsula College of Medicine and Dentistry, Exeter University, United Kingdom.

  • V. Ridde is associate professor at the School of Public Health and University of Montreal Hospital Research Centre in Canada.