National fee exemption schemes for deliveries: comparing the recent experiences of Ghana and Senegal

Abstract

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 focused attention on the importance of reducing financial barriers to skilled care. This article compares the findings of two studies on national policies exempting women from user fees for deliveries, conducted in Ghana in 2005-6 and in Senegal in 2006-7. The evaluations used a combination of research methods, including key informant interviews, household surveys, financial flows tracking, health worker incentive surveys, confidential enquiry, clinical case note record extraction, community level interviews and focus group discussions. The detailed findings from each evaluation are presented, followed by the broad lessons learnt from these similar (but not identical) policies. The policies shared goals, and both were implemented in poorer regions initially but then scaled up, using national resources. They demonstrate the potential of fee exemption policies to increase utilisation. The cost per additional assisted delivery was $62 (average) in Ghana and $21 (normal delivery) and $467 (caesarean section) in Senegal. There was also some evidence of reductions in inequalities of access. 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 studies also highlight the need to address quality of care and geographical access issues alongside fee exemption. A number of implementation lessons can be learnt, including the need for more robust analysis of bottlenecks; less haste in scaling up; establishing a better policy consensus; more detailed planning of implementation; thinking through the impact of a policy on incentives at facility and individual health worker level; and ensuring strong institutional leadership.