Search

While it is mandated that reproductive and child health services be provided for free at public facilities in India, qualitative evidence suggests it is common for facilities to request bribes and other informal payments for medicines, medical tests or equipment. This article examines the prevalence of bribe requests, total out-of-pocket expenditures (OOPEs) and associations between bribe requests and total OOPEs on the experience of quality of care and maternal complications during childbirth. Women who delivered in public facilities in Uttar Pradesh, India were administered a survey on sociodemographic characteristics, bribe requests, total OOPEs, types of health checks received and experience of maternal complications. Data were analysed using descriptive, bivariate and multivariate statistics. Among the 2018 women who completed the survey, 43% were asked to pay a bribe and 73% incurred OOPEs. Bribe requests were associated with lower odds of receiving all health checks upon arrival to the facility (aOR = 0.49; 95% CI: 0.24-0.98) and during labour and delivery (aOR = 0.44; 95% CI: 0.25-0.76), lower odds of receiving most or all health checks after delivery (aOR = 0.44; 95% CI: 0.31-0.62) and higher odds of experiencing maternal complications (aOR = 1.45; 95% CI: 1.13-1.87). Although it is mandated that maternity care be provided for free in public facilities in India, these findings suggest that OOPEs are high, and bribes/tips contribute significantly. Interventions centred on improving person-centred care (particularly guidelines around bribes), health system conditions and women's expectations of care are needed., (© The Author(s) 2020. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The private healthcare sector in low- and middle-income countries is increasingly seen as of public health importance, with widespread interest in improving private provider engagement. However, there is relatively little literature providing an in-depth understanding of the operation of private providers. We conducted a mixed methods analysis of the nature of competition faced by private delivery providers in Uttar Pradesh, India, where maternal mortality remains very high. We mapped health facilities in five contrasting districts, surveyed private facilities providing deliveries and conducted in-depth interviews with facility staff, allied providers (e.g. ambulance drivers, pathology laboratories) and other key informants. Over 3800 private facilities were mapped, of which 8% reported providing deliveries, mostly clustered in cities and larger towns. 89% of delivery facilities provided C-sections, but over half were not registered. Facilities were generally small, and the majority were independently owned, mostly by medical doctors and, to a lesser extent, AYUSH (non-biomedical) providers and others without formal qualifications. Recent growth in facility numbers had led to intense competition, particularly among mid-level facilities where customers were more price sensitive. In all facilities, nearly all payment was out-of-pocket, with very low-insurance coverage. Non-price competition was a key feature of the market and included location (preferably on highways or close to government facilities), medical infrastructure, hotel features, staff qualifications and reputation, and marketing. There was heavy reliance on visiting consultants such as obstetricians, surgeons and anaesthetists, and payment of hefty commission payments to agents who brought clients to the facility, for both new patients and those transferring from public facilities. Building on these insights, strategies for private sector engagement could include a foundation of universal facility registration, adaptation of accreditation schemes to lower-level facilities, improved third-party payment mechanisms and strategic purchasing, and enhanced patient information on facility availability, costs and quality., (© The Author(s) 2019. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

This study explores the relationship between two health financing initiatives on women's progression through the maternal health continuum in Kenya: a subsidized reproductive health voucher programme (2006-16) and the introduction of free maternity services in all government facilities (2013). Using cross-sectional survey data, we ran three multivariable logistic regression models examining the effects of the voucher programme, free maternity policy, health insurance and other determinants on (1) early antenatal care (ANC) initiation (first visit within the first trimester of pregnancy), (2) receiving continuous care (1+ ANC, facility birth, 1+ post-natal care (PNC) check) and (3) completing the maternal health pathway as recommended (4+ ANC, facility birth, 1+ PNC, with first check occurring within 48 h of delivery). Full implementation of the voucher programme was positively associated with receiving continuous care among users of 1+ ANC [interaction term adjusted odds ratio (aOR): 1.33, P = 0.014]. Early ANC initiation (aOR: 1.32, P = 0.001) and use of private sector ANC (aOR: 1.93, P < 0.001) were also positively associated with use of continuous care among ANC users. Among continuous care users, early ANC was associated with increased odds of completing the maternal health pathway as recommended (aOR: 3.80, P < 0.001). Higher parity was negatively associated with all three outcomes, while having health insurance was positively associated with each outcome. The impact of other sociodemographic factors such as maternal age, education, wealth quintile, urban residence, and employment varied by outcome; however, the findings generally suggest that marginalized women faced greater barriers to early ANC initiation and continuity of care. Health financing and women's timing and source of ANC are strongly related to their subsequent progression through the maternal health pathway. To increase continuity of care and improve maternal health outcomes, policymakers must therefore focus on equitably reducing financial and other barriers to care seeking and improving quality of care throughout the continuum., (© The Author(s) 2019. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Financial barriers cause many women in low- and middle-income countries to deliver outside of a health facility, contributing to maternal and neonatal mortality. Savings accrued during pregnancy can increase access to safe delivery services. We investigated the relationship between household saving during pregnancy and facility delivery. A cross-section of 2381 women who delivered a child in the previous 12 months was sampled from 40 health facility catchment areas across eight districts in three provinces in Zambia in April and May of 2016. During a household survey, women reported on their perceptions of the adequacy of their household savings during their recent pregnancy. Households were categorized based on women's responses as: did not save; saved but not enough; and saved enough. We estimated crude and adjusted associations between perceived adequacy of savings and facility delivery. We also explored associations between savings and expenditures on delivery. Overall, 51% of women surveyed reported that their household saved enough for delivery; 32% reported saving but not enough; and 17% did not save. Household wealth was positively associated with both categories of saving, while earlier attendance at antenatal care was positively associated with saving enough. Compared with women in households that did not save, those in households that saved but not enough (aOR 1.63; 95% CI: 1.17, 2.25) and saved enough (aOR 2.86; 95% CI: 2.05, 3.99) had significantly higher odds of facility delivery. Both categories of saving were significantly associated with higher overall expenditure on delivery, driven in large part by higher expenditures on baby clothes and transportation. Our findings suggest that interventions that encourage saving early in pregnancy may improve access to facility delivery services., (© The Author(s) 2019. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

The impact of payment-for-performance (P4P) schemes in the health sector has been documented, but there has been little attention to the distributional effects of P4P across health facilities. We examined the distribution of P4P payouts over time and assessed whether increased service coverage due to P4P differed across facilities in Tanzania. We used two service outcomes that improved due to P4P [facility-based deliveries and provision of antimalarials during antenatal care (ANC)], to also assess whether incentive design matters for performance inequalities. We used data from 150 facilities from intervention and comparison areas in January 2012 and 13 months later. Our primary data were gathered through facility survey and household survey, while data on performance payouts were obtained from the programme administrator. Descriptive inequality measures were used to examine the distribution of payouts across facility subgroups. Difference-in-differences regression analyses were used to identify P4P differential effects on the two service coverage outcomes across facility subgroups. We found that performance payouts were initially higher among higher-level facilities (hospitals and health centres) compared with dispensaries, among facilities with more medical commodities and among facilities serving wealthier populations, but these inequalities declined over time. P4P had greater effects on coverage of institutional deliveries among facilities with low baseline performance, serving middle wealth populations and located in rural areas. P4P effects on antimalarials provision during ANC was similar across facilities. Performance inequalities were influenced by the design of incentives and a range of facility characteristics; however, the nature of the service being targeted is also likely to have affected provider response. Further research is needed to examine in more detail the effects of incentive design on outcomes and researchers should be encouraged to report on design aspects in their evaluations of P4P and systematically monitor and report subgroup effects across providers.

User fee reduction and removal policies have been the object of extensive research, but little rigorous evidence exists on their sustained effects in relation to use of delivery care services, and no evidence exists on the effects of partial reduction compared with full removal of user fees. We aimed to fill these knowledge gaps by assessing sustained effects of both partial reduction and complete removal of user fees on utilization of facility-based delivery. Our study took place in four districts in the Sahel region of Burkina Faso, where the national user fee reduction policy (SONU) launched in 2007 (lowering fees at point of use by 80%) co-existed with a user fee removal pilot launched in 2008. We used Health Management Information System data to construct a controlled interrupted time-series analysis and examine both immediate and sustained effects of SONU and the pilot from January 2004 to December 2014. We found that both SONU and the pilot led to a sustained increase in the use of facility-based delivery. SONU produced an accumulative increase of 31.4% (P < 0.01) over 8 years in the four study districts. The pilot further enhanced utilization and produced an additional increase of 23.2% (P < 0.001) over 6 years. These increasing trends did not continue to reach full coverage, i.e. ensuring that all women had a facility-based delivery. Instead, they stabilized 3 years and 4 years after the onset of SONU and the pilot, respectively. Our study provides further evidence that user fee reduction and removal policies are effective in increasing service use in the long term. However, they alone are not sufficient to achieve full coverage. This calls for the need to implement additional measures, targeting for instance geographical barriers and knowledge gaps, to achieve the target of all women delivering in the presence of a skilled attendant.

Analysing why certain information spreads-or not-can be highly relevant for understanding an intervention's potential impact. Two recently implemented policy changes related to EMTCT (elimination of mother-to-child transmission of HIV) in the Balaka district of Malawi give ample opportunity to assess how new information trickles through a targeted rural community. One of the policies entails the lifetime provision of ART (anti-retroviral therapy) to all HIV+ pregnant women-a governmental strategy to EMTCT first initiated in Malawi and now being expanded throughout the region. The second new policy concerns a pilot project in which women are financially rewarded for attending antenatal care and delivering in the hospital. An in-depth anthropological approach was used to assess what women in one village community know about the policy changes and how they had come to know about it. Although the policies were implemented more or less at the same time, awareness and knowledge levels among village women differed largely: In case of the first, awareness stagnated at the level of those who directly received the information from health professionals. In the case of the second, highly accurate and up-to-date knowledge had spread throughout the village community. I suggest three reasons for this divergence: (i) perceived talk-worthiness of (issues addressed by) the interventions, (ii) motives for hiding or disclosing involvement in either of the interventions and (iii) the visibility of each intervention, or in other words, the (im)possibility to hide involvement. I argue that these reasons for women's structural silence on one policy change and prompt sharing of information on another follow a distinctly gendered logic. The findings underline that the diffusion of new information is to a great extent shaped by the social particularities of the context in which it is introduced., (© The Author 2017. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Payments to users and providers of health services are an important ingredient in attempts to promote universal health coverage in low resource settings. The maternal health programme in Nepal explicitly recognizes that ensuring universal access to safe delivery care requires policies that both ensure effective services and overcome demand-side barriers. The programme has used three innovative financing initiatives to stimulate an increase in the use of facility-based delivery: the maternity incentive scheme (2005) reimbursing women for accessing a facility, activity payments in poor districts (2006) and universal free-delivery (2009). We examine the impact of these mechanisms on access to safe delivery services. Multiple waves of the Demographic and Health Survey were merged to provide household-level cross-sectional data on maternity services. A multilevel logit model was used to investigate the roll-out of the three policies across ecological zones assuming a district-wide treatment effect. An interrupted time-series approach that includes cross sectional data on deliveries at each period is used to detect the association between outcomes and policy. The maternal Incentive programme was associated with an increase in service delivery in hill and tarai areas. A positive effect in mountain areas was detectable as a result of the supply side payments made to facilities for delivery. Although use among the non-poor increased across the country, a positive effect on the poorest population was only present in mountain areas. The beneficial impact of maternal financing policies in Nepal is skewed towards areas and households that are geographically more accessible and wealthy. Inferior services in remote areas reduce the impact of financing policies. Policy may need to be refocused on poorer, less accessible areas if improvements in access to maternal health services are to continue., (© The Author 2017. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Despite health systems improvements in Tanzania, gaps in the continuum of care for maternal, newborn and child health persist. Recent improvements have largely benefited those over one month of age, leading to a greater proportion of under-five mortality in newborns. Community health workers providing home-based counselling have been championed as uniquely qualified to reach the poorest. We provide financial and economic costs of a volunteer home-based counselling programme in southern Tanzania. Financial costs of the programme were extracted from project accounts. Ministry of Health and Social Welfare costs associated with programme implementation were collected based on staff and project monthly activity plans. Household costs associated with facility-based delivery were also estimated based on exit interviews with post-natal women. Time spent on the programme by implementers was assessed by interviews conducted with volunteers and health staff. The programme involved substantial design and set-up costs. The main drivers of set-up costs were activities related to volunteer training. Total annualized costs (design, set-up and implementation) amounted to nearly US$300 000 for financial costs and just over US$400 000 for economic costs. Volunteers (n = 842) spent just under 14 hours per month on programme-related activities. When volunteer time was valued under economic costs, this input amounted to just under half of the costs of implementation. The economic consequences of increased service use to households were estimated at US$36 985. The intervention cost per mother-newborn pair visited was between US$12.60 and US$19.50, and the incremental cost per additional facility-based delivery ranged from US$85.50 to US$137.20 for financial and economic costs (with household costs). Three scale-up scenarios were considered, with the financial cost per home visit respectively varying from $1.44 to $3.21 across scenarios. Cost-effectiveness compares well with supply-side initiatives to increase coverage of facility-based deliveries, and the intervention would benefit from substantial economies of scale., (© The Author 2016. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Many countries, especially in Africa, have in recent years introduced fee exemptions or subsidies targeting deliveries and emergency obstetric care. A number of aspects of these policies have been studied but there are few studies which look at how staff have been affected and how they have responded. This article focuses on this question, comparing data from Benin, Burkina Faso, Mali and Morocco. It is nested in wider evaluation of the policies. The article analyses responses to a health worker survey, carried out in 2012 on 683 health staff (doctors, nurses, midwives and others such as auxiliaries) across the four countries. The survey focused on working hours, workloads, pay, motivation and perceptions of the policies, as well as reported changes in workload and remuneration over the period of policy introduction. Self-reported staff output ratios suggest that midwives are over-worked across all settings, but facility data presents lower estimates, making it hard to judge the adequacy of workforces. Staff are generally positive about the policies’ effects on the health system (increasing supervised delivery rates, benefiting the poor, improving access to medicines and supplies and improving quality of care). In personal terms, staff in Mali and Burkina Faso report increased satisfaction with work as a result of the policies, while in Benin, there is little change and in Morocco a deterioration (which correlated with recommendations about extending exemption policies in future). Awareness of policies was high amongst staff but only a small minority had received any written guides or training on policy implementation. It is crucial that planned health financing changes engage with their implications for staffing—estimating whether specific cadres can absorb increase demand, for example, as well as how to engage them in the policy implementation such that their personal needs are met and their professionalism enhanced.

Reducing child and maternal mortality in order to meet the health-related Millennium Development Goals (MDGs) 4 and 5 remains a major challenge in Myanmar. Inadequate care during pregnancy and labour plays an important role in the maternal mortality rate in Myanmar. A Maternal and Child Health (MCH) Voucher Scheme comprising a subsidization for pregnant women to receive four antenatal care (ANC), delivery and postnatal care (PNC) free-of-charge was planned to help women overcome financial barriers in addition to raising awareness of ANC and delivery with skilled birth attendants (SBA), which can reduce the rate of maternal and neonatal death. This study is part of an ex-ante evaluation of a feasibility study of the MCH Voucher Scheme. A cost-utility analysis was conducted using a decision tree model to assess the cost per disability-adjusted life years (DALYs) averted from the MCH Voucher Scheme compared with the current situation. Most input parameters were obtained from Myanmar context. From the base-case analysis, where the financial burden on households was fully subsidized, the MCH Voucher Scheme increased utilization for ANC from 73% up to 93% and for delivery from SBAs from 51% up to and 71%, respectively; hence, it is considered to be very cost-effective with an incremental cost-effectiveness ratio of 381 027 kyats per DALY averted (2010, price year). From the probabilistic sensitivity analysis, the MCH Voucher Scheme had a 52% chance of being a cost-effective option at 1 GDP per capita threshold compared to the current situation. Given that the Voucher Scheme is currently being implemented in one township in Myanmar as a result of this study, ongoing evaluation of the effectiveness and cost-effectiveness of this scheme is warranted., (© The Author 2015. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Background: In Sub-Saharan Africa, maternal and neonatal morbidity and mortality rates are associated with underutilization of skilled birth attendance (SBA). In 2007, Burkina Faso introduced a subsidy scheme for SBA fees. The objective of this study was to evaluate the effect of Burkina Faso's subsidy policy on SBA rate across socioeconomic status (SES) strata., Methods: We used a quasi-experimental design. The data sources were two representative surveys (n = 1408 and n = 1403) of women from Houndé and Ziniaré health districts of Burkina Faso, and a survey of health centres assessing structural quality of care. Multilevel Poisson regression models were used with robust variance estimators. We estimated adjusted rate ratios (RR) and rate differences (RD) as a function of time and SES., Results: For lowest-SES women, immediately upon the introduction of the subsidy policy, the rate of SBA was 45% higher (RR = 1.45, 95% confidence interval (CI): 1.19-1.77) than expected in the absence of subsidy introduction. The results indicated a sustained effect after introduction of the subsidy policy, based on RR estimate (95% CI) of 1.48 (1.21-1.81) at 2 years. For middle-SES women, the RR estimates were 1.28 (1.09-1.49) immediately after introduction of the subsidy policy and 1.30 (1.11-1.51) at 2 years, respectively. For highest-SES women, the RR estimates were 1.19 (1.02-1.38) immediately after subsidy introduction and 1.21 (1.06-1.38) at 2 years, respectively. The RD (95% CI) was 14% (3-24%) for lowest-SES women immediately after introduction of the policy, and the effect was sustained at 14% (4-25%) at 2 years., Conclusion: Our study suggests that the introduction of a user-fee subsidy in Burkina Faso resulted in increased rates of SBA across all SES strata. The increase was sustained over time and strongest among the poorest women. These findings have important implications for evidence-informed policy making in Burkina Faso and other countries in Sub-Saharan Africa., (© The Author 2015. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Background: Several countries in sub-Saharan Africa have recently adopted policies that remove user fees for facility-based delivery services. There is little rigorous evidence of the impact of these policies on utilization of delivery services and no evaluations have examined effects on neonatal mortality rates (NMR). In this article, we estimate the causal effect of removing user fees on the proportion of births delivered in facilities, the proportion of births delivered by Caesarean section, and NMR., Methods: We used data from Demographic and Health Surveys conducted in 10 African countries between 1997 and 2012. Kenya, Ghana and Senegal adopted policies removing user fees for facility-based deliveries between 2003 and 2007, while seven other countries not changing user fee policies were used as controls. We used a difference-in-differences (DD) regression approach to control for secular trends in the outcomes that are common across countries and for time invariant differences between countries., Results: According to covariate-adjusted DD models, the policy change was consistent with an increase of 3.1 facility-based deliveries per 100 live births (95% confidence interval (CI): 0.9, 5.2) and an estimated reduction of 2.9 neonatal deaths per 1000 births (95% CI: -6.8, 1.0). In relative terms, this corresponds to a 5% increase in facility deliveries and a 9% reduction in NMR. There was no evidence of an increase in Caesarean deliveries. We examined lead and lag-time effects, finding evidence that facility deliveries continued to increase following fee removal., Conclusions: Our findings suggest removing user fees increased facility-based deliveries and possibly contributed to a reduction in NMR. Evidence from this evaluation may be useful to governments weighing the potential benefits of removing user fees., (Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2014; all rights reserved.)

Burkina Faso implemented a national subsidy for emergency obstetric and neonatal care (EmONC) covering 80% of the cost of normal childbirth in public health facilities. The objective was to increase coverage of facility-based deliveries. After implementation of the EmONC policy, coverage increased across the country, but disparities were observed between districts and between primary healthcare centres (PHC). To understand the variation in coverage, we assessed the contextual factors and the implementation of EmONC in six PHCs in a district. We conducted a contrasted multiple case study. We interviewed women (n = 71), traditional birth attendants (n = 7), clinic management committees (n = 11), and health workers and district health managers (n = 26). Focus groups (n = 62) were conducted within communities. Observations were carried out in the six PHCs. Implementation was nearly homogeneous in the six PHCs but the contexts and human factors appeared to explain the variations observed on the coverage of facility-based deliveries. In the PHCs of Nogo and Tara, the immediate increase in coverage was attributed to health workers' leadership in creatively promoting facility-based deliveries and strengthening relationships of trust with communities, users' positive perceptions of quality of care and the arrival of female professional staff. The change of healthcare team at Iata's PHC and a penalty fee imposed for home births in Belem may have caused the delayed effects there. Finally, the unchanged coverage in the PHCs of Fati and Mata was likely due to lack of promotion of facility-based deliveries, users' negative perceptions of quality of care, and conflicts between health workers and users. Before implementation, decision-makers should perform pilot studies to adapt policies according to contexts and human factors., (Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2014; all rights reserved.)

There has been increased interest in and experimentation with demand-side mechanisms such as the use of vouchers that place purchasing power in the hands of targeted consumers to improve the uptake of healthcare services in low-income settings. A key measure of the success of such interventions is the extent to which the programmes have succeeded in reaching the target populations. This article estimates the coverage of facility deliveries by a maternal health voucher programme in South-western Uganda and examines whether such coverage is correlated with district-level characteristics such as poverty density and the number of contracted facilities. Analysis entails estimating the voucher coverage of health facility deliveries among the general population and poor population (PP) using programme data for 2010, which was the most complete calendar year of implementation of the Uganda safe motherhood (SM) voucher programme. The results show that: (1) the programme paid for 38% of estimated deliveries among the PP in the targeted districts, (2) there was a significant negative correlation between the poverty density in a district and proportions of births to poor women that were covered by the programme and (3) improving coverage of health facility deliveries for poor women is dependent upon increasing the sales and redemption rates. The findings suggest that to the extent that the programme stimulated demand for SM services by new users, it has the potential of increasing facility-based births among poor women in the region. In addition, the significant negative correlation between the poverty density and the proportions of facility-based births to poor women that are covered by the voucher programme suggests that there is need to increase both voucher sales and the rate of redemption to improve coverage in districts with high levels of poverty., (Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2013; all rights reserved.)

Context: Though promotion of institutional delivery is used as a strategy to reduce maternal and neonatal mortality, about half of the deliveries in India are conducted at home without any medical care. Among women who deliver at home, one in four cites cost as barrier to facility-based care. The relative share of deliveries in private health centres has increased over time and the associated costs are often catastrophic for poor households. Though research has identified socio-economic, demographic and geographic barriers to the utilization of maternal care, little is known on the cost differentials in delivery care in India., Objective: The objective of this paper is to understand the regional pattern and socio-economic differentials in out-of-pocket (OOP) expenditure on institutional delivery by source of provider in India., Methods: The study utilizes unit data from the District Level Household and Facility Survey (DLHS-3), conducted in India during 2007-08. Descriptive statistics, principal component analyses and a two-part model are used in the analyses., Findings: During 2004-08, the mean OOP expenditure for a delivery in a public health centre in India was US$39 compared with US$139 in a private health centre. The predicted expenditure for a caesarean delivery was six times higher than for a normal delivery. With an increase in the economic status and educational attainment of mothers, the propensity and rate of OOP expenditure increases, linking higher OOP expenditure to quality of care. The OOP expenditure in public health centres, adjusting for inflation, has declined over time, possibly due to increased spending under the National Rural Health Mission. Based on these findings, we recommend that facilities in public health centres of poorly performing states are improved and that public-private partnership models are developed to reduce the economic burden for households of maternal care in India.

This paper examines community-level association between exposure to the reproductive health vouchers programme in Kenya and utilization of services. The data are from a household survey conducted among 2527 women (15-49 years) from voucher and comparable non-voucher sites. Analysis entails cross-tabulations with Chi-square tests and significant tests of proportions as well as estimation of multi-level logit models to predict service utilization by exposure to the programme. The results show that for births occurring after the voucher programme began, women from communities that had been exposed to the programme since 2006 were significantly more likely to have delivered at a health facility and to have received skilled care during delivery compared with those from communities that had not been exposed to the programme at all. There were, however, no significant differences in the timing of first trimester utilization of antenatal care (ANC) and making four or more ANC visits by exposure to the programme. In addition, poor women were significantly less likely to have used safe motherhood services (health facility delivery, skilled delivery care and postnatal care) compared with their non-poor counterparts regardless of exposure to the programme. Nonetheless, a significantly higher proportion of poor women from communities that had been exposed to the programme since 2006 used the services compared with their poor counterparts from communities that had not been exposed to the programme at all. The findings suggest that the programme is associated with increased health facility deliveries and skilled delivery care especially among poor women. However, it has had limited community-level impact on the first trimester timing of antenatal care use and making four or more visits, which remain a challenge despite the high proportion of women in the country that make at least one antenatal care visit during pregnancy.

Objective: To measure whether there was an association between the introduction of an output-based voucher programme and the odds of a facility-based delivery in two Nairobi informal settlements., Data Sources: Nairobi Urban Health and Demographic Surveillance System (NUHDSS) and two cross-sectional household surveys in Korogocho and Viwandani informal settlements in 2004-05 and 2006-08., Methods: Odds of facility-based delivery were estimated before and after introduction of an output-based voucher. Supporting NUHDSS data were used to determine whether any trend in maternal health care was coincident with immunizations, a non-voucher outpatient service. As part of NUHDSS, households in Korogocho and Viwandani reported place of delivery and the presence of a skilled birth attendant (2003-10) and vaccination coverage (2003-09). A detailed maternal and child health (MCH) tool was added to NUHDSS (September 2006-10). Prospective enrolment in NUHDSS-MCH was conditional on having a newborn after September 2006. In addition to recording mother's place of delivery, NUHDSS-MCH recorded the use of the voucher., Findings: There were significantly greater odds of a facility-based delivery among respondents during the voucher programme compared with similar respondents prior to voucher launch. Testing whether unrelated outpatient care also increased, a falsification exercise found no significant increase in immunizations for children 12-23 months of age in the same period. Although the proportion completing any antenatal care (ANC) visit remained above 95% of all reported pregnancies and there was a significant increase in facility-based deliveries, the proportion of women completing 4+ ANC visits was significantly lower during the voucher programme., Conclusions: A positive association was observed between vouchers and facility-based deliveries in Nairobi. Although there is a need for higher quality evidence and validation in future studies, this statistically significant and policy relevant finding suggests that increases in facility-based deliveries can be achieved through output-based finance models that target subsidies to underserved populations.

Introduction: To reduce financial barriers to health care services presented by user fees, Burkina Faso adopted a policy to subsidize deliveries and emergency obstetric care for the period 2006-2015. Deliveries and caesarean sections are subsidized at 80%; women must pay the remainder. The worst-off are fully exempted. METHODS The aim of this article is to document this policy's entire process using a health policy analytical framework. Qualitative data are drawn from individual interviews (n = 113 persons) and focus groups conducted with 344 persons in central government, three rural districts and one urban district. Quantitative data are taken from the national health information system in eight districts. RESULTS The policy was initiated in all districts concurrently, before all the technical instruments were ready. The subsidy is paid by the national budget (US$60 million, including US$10 million for the worst-off). Information activities, implementation and evaluation support have been minimal because of insufficient funding. Health workers and lay people have not always had the same information, such that the policy has not been uniformly applied. Coping strategies have been noted among health workers and the population, but there has been no attempt to impede the policy's implementation. At the time of the study, fixed-rate reimbursement for delivery (output-based) and overestimation of input costs were financially advantageous to health workers (bonuses) and management committees (hoarding). Very few of the worst-off have been exempted from payment because selection processes and criteria have not yet been defined and most health workers are unaware of this possibility. The upward trend in assisted deliveries since 2004 continued after the policy's introduction. CONCLUSIONS This ambitious policy expresses a strong political commitment but has not been adequately supported by international partners. Despite relatively tight administrative controls, health workers have figured out how to take advantage of the system. Some of the policy's instruments should be reviewed and clarified to improve its effectiveness.

This paper estimates the total cost to women and their families associated with a spontaneous vaginal delivery and five types of 'near-miss' obstetric complication in Benin and Ghana, and assesses affordability in relation to household cash expenditure. A retrospective evaluation of costs was carried out among 121 mothers in three hospitals in Ghana. A prospective evaluation of costs was undertaken among 420 pregnant women in two hospitals in Benin. Information was collected on the cost of travel to the facilities and of direct medical and non-medical costs incurred during their stay in hospital. In Benin, costs ranged from an average of 15 US dollars for a spontaneous delivery to 256 US dollars for a near-miss complication caused by dystocia. In Ghana, average costs ranged from 18 US dollars for a spontaneous vaginal delivery to 115 US dollars for a near-miss complication caused by haemorrhage. Medical costs accounted for the largest share of total costs, mainly drugs and medical supplies in Ghana and costs of the delivery and any surgical intervention in Benin. Payments associated with a spontaneous vaginal delivery amounted to at least 2% of annual household cash expenditure in both countries. In the case of severe obstetric complications, costs incurred reached a high of 34% of annual household cash expenditure in Benin. The economic burden of hospital-based delivery care in Ghana and Benin is likely to deter or delay women's use of health services. Should a woman develop severe obstetric complications while in labour, the relatively high costs of hospital care could have a potentially catastrophic impact on the household budget.

We studied the cost and affordability of 'free' maternity services at government facilities in Dhaka, Bangladesh, to assess whether economic factors may contribute to low utilization. We conducted a questionnaire survey and in-depth interviews among 220 post-partum mothers and their husbands, selected from four government maternity facilities (three referral hospitals and one Mother and Child Health hospital) in Dhaka. Mothers with serious complications were excluded. Information was collected on the costs of maternity care, household income, the sources of finance used to cover the costs, and the family's willingness to pay for maternity services. The mean cost for normal delivery was 1275 taka (US$31.9) and for caesarean section 4703 taka (US$117.5). Average monthly household income was 4933 taka (US$123). Twenty-one per cent of families were spending 51-100% of monthly income, and 27% of families 2-8 times their monthly income for maternity care. Overall, 51% of the families (and 74% of those having a caesarean delivery) did not have enough money to pay; of these, 79% had to borrow from a money lender or relative. Surprisingly, 72% of the families said they were willing to pay a government-levied user charge, though this was less popular among low-income families (61%). 'Free' maternity care in Bangladesh involves considerable hidden costs which may be a major contributor to low utilization of maternity services, especially among low-income groups. To increase utilization of safer motherhood services, policy-makers might consider introducing fixed user charges with clear exemption guidelines, or greater subsidies for existing services, especially caesarean section.