Making delivery care free : evidence from Ghana and Senegal on implementation, costs and effectiveness of national delivery exemption policies

• Main Author: Witter, Sophie
• Published: University of Aberdeen 2009
• Subjects: 337; Maternal health services : Medical economics : Obstetrics : Women’s health services
• Online Access: http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.499745

Continuing high maternal mortality ratios, especially in Africa, and high discrepancies between richer and poorer households in relation to access to maternal health care and maternal health status have focussed attention on the importance of reducing financial barriers to skilled care. This PhD compares the findings of two evaluations of national policies exempting women from user fees for deliveries, conducted in Ghana in 2005-6 and in Senegal in 2006-7. The detailed findings from each evaluation are presented as well as the broad lessons learnt from what are similar (but not identical) policies with similar goals, both of which were implemented in poorer regions initially but then scaled up, using national resources.  Both demonstrate the potential of fee exemption policies to increase utilisation.  The cost per additional associated delivery was $62 (average) in Ghana and $21 (normal delivery) and $457 (caesarean section) in Senegal. However, despite reducing direct costs for women (from $195 to $153 for caesareans and from $42 to $34 for normal deliveries in Ghana), in neither country were delivery fees costs reduced to zero.  This was linked to a number of important factors, including inadequate budgets (in Ghana) and failure to adequately reimburse lower level providers (in Senegal).  The study also highlights the need to address quality of care and geographical access issues alongside fee exemption. While there has been a lot of debate over the relative merits of different targeting approaches and design of policies to reduce financial barriers to health care (maternal and general), the Ghana and Senegal evaluations suggest the details of implementation and their interaction with contextual factors can be more significant than design of the policy per se.