3 research outputs found
Cost and impact of policies to remove and reduce fees for obstetric care in Benin, Burkina Faso, Mali and Morocco
Background: Across the Africa region and beyond, the last decade has seen many countries introducing policies
aimed at reducing financial barriers to obstetric care. This article provides evidence of the cost and effects of
national policies focussed on improving financial access to caesarean and facility deliveries in Benin, Burkina Faso,
Mali and Morocco.
Methods: The study uses a comparative case study design with mixed methods, including realist evaluation
components. This article presents results across 14 different data collection tools, used in 4-6 research sites in each
of the four study countries over 2011-13. The methods included: document review; interviews with key informants;
analysis of secondary data; structured extraction from medical files; cross-sectional surveys of patients and staff;
interviews with patients and observation of care processes.
Results: The article finds that the policies have contributed to continued increases in skilled birth attendance and
caesarean sections and a narrowing of inequalities in all four countries, but these trends were already occurring so
a shift cannot be attributed solely to the policies. It finds a significant reduction in financial burdens on households
after the policy, suggesting that the financial protection objectives may have been met, at least in the short term,
although none achieved total exemption of targeted costs. Policies are domestically financed and are potentially
sustainable and efficient, and were relatively thoroughly implemented. Further, we find no evidence of negative
effects on technical quality of care, or of unintended negative effects on untargeted services.
Conclusions: We conclude that the policies were effective in meeting financial protection goals and probably
health and equity goals, at sustainable cost, but that a range of measures could increase their effectiveness and
equity. These include broadening the exempted package (especially for those countries which focused on
caesarean sections alone), better calibrated payments, clearer information on policies, better stewardship of the
local health system to deal with underlying systemic weaknesses, more robust implementation of exemptions for
indigents, and paying more attention to quality of care, especially for newborns.sch_iih15pub4430pub
'Rowing against the current': The policy process and effects of removing user fees for caesarean sections in Benin
Background In 2009, the Benin government introduced
a user fee exemption policy for caesarean sections. We
analyse this policy with regard to how the existing ideas
and institutions related to user fees influenced key steps
of the policy cycle and draw lessons that could inform the
policy dialogue for universal health coverage in the West
African region.
Methods Following the policy stages model, we analyse
the agenda setting, policy formulation and legitimation
phase, and assess the implementation fidelity and policy
results. We adopted an embedded case study design, using
quantitative and qualitative data collected with 13 tools at
the national level and in seven hospitals implementing the
policy.
Results We found that the initial political goal of the policy
was not to reduce maternal mortality but to eliminate
the detention in hospitals of mothers and newborns who
cannot pay the user fees by exempting a comprehensive
package of maternal health services. We found that the
policy development process suffered from inadequate
uptake of evidence and that the policy content and process
were not completely in harmony with political and public
health goals. The initial policy intention clashed with
the neoliberal orientation of the political system, the fee
recovery principles institutionalised since the Bamako
Initiative and the prevailing ideas in favour of user fees.
The policymakers did not take these entrenched factors
into account. The resulting tension contributed to a benefit
package covering only caesarean sections and to the
variable implementation and effectiveness of the policy.
Conclusion The influence of organisational culture in
the decision-making processes in the health sector is
often ignored but must be considered in the design and
implementation of any policy aimed at achieving universal
health coverage in West African countries.sch_iih3pub5185pub1 [e000537
Frequency and management of maternal infection in health facilities in 52 countries (GLOSS): a 1-week inception cohort study
Background Maternal infections are an important cause of maternal mortality and severe maternal morbidity. We report the main findings of the WHO Global Maternal Sepsis Study, which aimed to assess the frequency of maternal infections in health facilities, according to maternal characteristics and outcomes, and coverage of core practices for early identification and management. Methods We did a facility-based, prospective, 1-week inception cohort study in 713 health facilities providing obstetric, midwifery, or abortion care, or where women could be admitted because of complications of pregnancy, childbirth, post-partum, or post-abortion, in 52 low-income and middle-income countries (LMICs) and high-income countries (HICs). We obtained data from hospital records for all pregnant or recently pregnant women hospitalised with suspected or confirmed infection. We calculated ratios of infection and infection-related severe maternal outcomes (ie, death or near-miss) per 1000 livebirths and the proportion of intrahospital fatalities across country income groups, as well as the distribution of demographic, obstetric, clinical characteristics and outcomes, and coverage of a set of core practices for identification and management across infection severity groups. Findings Between Nov 28, 2017, and Dec 4, 2017, of 2965 women assessed for eligibility, 2850 pregnant or recently pregnant women with suspected or confirmed infection were included. 70·4 (95% CI 67·7–73·1) hospitalised women per 1000 livebirths had a maternal infection, and 10·9 (9·8–12·0) women per 1000 livebirths presented with infection-related (underlying or contributing cause) severe maternal outcomes. Highest ratios were observed in LMICs and the lowest in HICs. The proportion of intrahospital fatalities was 6·8% among women with severe maternal outcomes, with the highest proportion in low-income countries. Infection-related maternal deaths represented more than half of the intrahospital deaths. Around two-thirds (63·9%, n=1821) of the women had a complete set of vital signs recorded, or received antimicrobials the day of suspicion or diagnosis of the infection (70·2%, n=1875), without marked differences across severity groups. Interpretation The frequency of maternal infections requiring management in health facilities is high. Our results suggest that contribution of direct (obstetric) and indirect (non-obstetric) infections to overall maternal deaths is greater than previously thought. Improvement of early identification is urgently needed, as well as prompt management of women with infections in health facilities by implementing effective evidence-based practices