Did the strategy of skilled attendance at birth reach the poor in Indonesia?

Objective To assess whether the strategy of “a midwife in every village” in Indonesia achieved its aim of increasing professional delivery care for the poorest women. Methods Using pooled Demographic and Health Surveys (DHS) data from 1986–2002, we examined trends in the percentage of births attended by a health professional and deliveries via caesarean section. We tested for effects of the economic crisis of 1997, which had a negative impact on Indonesia’s health system. We used logistic regression, allowing for time-trend interactions with wealth quintile and urban/rural residence. Findings There was no change in rates of professional attendance or caesarean section before the programme’s full implementation (1986–1991). After 1991, the greatest increases in professional attendance occurred among the poorest two quintiles – 11% per year compared with 6% per year for women in the middle quintile ( P = 0.02). These patterns persisted after the economic crisis had ended. In contrast, most of the increase in rates of caesarean section occurred among women in the wealthiest quintile. Rates of caesarean deliveries remained at less than 1% for the poorest two-fifths of the population, but rose to 10% for the wealthiest fifth. Conclusion The Indonesian village midwife programme dramatically reduced socioeconomic inequalities in professional attendance at birth, but the gap in access to potentially life-saving emergency obstetric care widened. This underscores the importance of understanding the barriers to accessing emergency obstetric care and of the ways to overcome them, especially among the poor

Effect of Health Insurance on the Use and Provision of Maternal Health Services and Maternal and Neonatal Health Outcomes: A Systematic Review

Financial barriers can affect timely access to maternal health services. Health insurance can influence the use and quality of these services and potentially improve maternal and neonatal health outcomes. We conducted a systematic review of the evidence on health insurance and its effects on the use and provision of maternal health services and on maternal and neonatal health outcomes in middle- and low-income countries. Studies were identified through a literature search in key databases and consultation with experts in healthcare financing and maternal health. Twenty-nine articles met the review criteria of focusing on health insurance and its effect on the use or quality of maternal health services, or maternal and neonatal health outcomes. Sixteen studies assessed demand-side effects of insurance, eight focused on supply-side effects, and the remainder addressed both. Geographically, the studies provided evidence from sub-Saharan Africa (n=11), Asia (n=9), Latin America (n=8), and Turkey. The studies included examples from national or social insurance schemes (n=7), government-run public health insurance schemes (n=4), community-based health insurance schemes (n=11), and private insurance (n=3). Half of the studies used econometric analyses while the remaining provided descriptive statistics or qualitative results. There is relatively consistent evidence that health insurance is positively correlated with the use of maternal health services. Only four studies used methods that can establish this causal relationship. Six studies presented suggestive evidence of overprovision of caesarean sections in response to providers\u2019 payment incentives through health insurance. Few studies focused on the relationship between health insurance and the quality of maternal health services or maternal and neonatal health outcomes. The available evidence on the quality and health outcomes is inconclusive, given the differences in measurement, contradictory findings, and statistical limitations. Consistent with economic theories, the studies identified a positive relationship between health insurance and the use of maternal health services. However, more rigorous causal methods are needed to identify the extent to which the use of these services increases among the insured. Better measurement of quality and the use of cross-country analyses would solidify the evidence on the impact of insurance on the quality of maternal health services and maternal and neonatal health outcomes

Effects of User Fee Exemptions on the Provision and Use of Maternal Health Services: A Review of Literature

User fee removal has been put forward as an approach to increasing priority health service utilization, reducing impoverishment, and ultimately reducing maternal and neonatal mortality. However, user fees are a source of facility revenue in many low-income countries, often used for purchasing drugs and supplies and paying incentives to health workers. This paper reviews evidence on the effects of user fee exemptions on maternal health service utilization, service provision, and outcomes, including both supply-side and demand-side effects. We reviewed 19 peer-reviewed research articles addressing user fee exemptions and maternal health services or outcomes published since 1990. Studies were identified through a USAIDcommissioned call for evidence, key word search, and screening process. Teams of reviewers assigned criteria- based quality scores to each paper and prepared structured narrative reviews. The grade of the evidence was found to be relatively weak, mainly from short-term, non-controlled studies. The introduction of user fee exemptions appears to have resulted in increased rates of facility-based deliveries and caesarean sections in some contexts. Impacts on maternal and neonatal mortality have not been conclusively demonstrated; exemptions for delivery care may contribute to modest reductions in institutional maternal mortality but the evidence is very weak. User fee exemptions were found to have negative, neutral, or inconclusive effects on availability of inputs, provider motivation, and quality of services. The extent to which user fee revenue lost by facilities is replaced can directly affect service provision and may have unintended consequences for provider motivation. Few studies have looked at the equity effects of fee removal, despite clear evidence that fees disproportionately burden the poor. This review highlights potential and documented benefits (increased use of maternity services) as well as risks (decreased provider motivation and quality) of user fee exemption policies for maternal health services. Governments should link user fee exemption policies with the replacement of lost revenue for facilities as well as broader health system improvements, including facility upgrades, ensured supply of needed inputs, and improved human resources for health. Removing user fees may increase uptake but will not reduce mortality proportionally if the quality of facility-based care is poor. More rigorous evaluations of both demand- and supply-side effects of mature fee exemption programmes are needed

Social security health insurance for the informal sector in Nicaragua: a randomized evaluation

This article presents the results from an experimental evaluation of a voluntary health insurance program for informal sector workers in Nicaragua. Costs of the premiums as well as enrollment location were randomly allocated. Overall, take-up of the program was low, with only 20% enrollment. Program costs and streamlined bureaucratic procedures were important determinants of enrollment. Participation of local microfinance institutions had a slight negative effect on enrollment. One year later, those who received insurance substituted toward services at covered facilities and total out-of-pocket expenditures fell. However, total expenditures fell by less than the insurance premiums. We find no evidence of an increase in health-care utilization among the newly insured. We also find very low retention rates after the expiration of the subsidy, with less than 10% of enrollees still enrolled after one year. To shed light on the findings from the experimental results, we present qualitative evidence of institutional and contextual factors that limited the success of this program. Copyright © 2010 John Wiley & Sons, Ltd.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/77966/1/1635_ftp.pd

Financial Incentives and Maternal Health: Where Do We Go from Here?

Health financing strategies that incorporate financial incentives are being applied in many low- and middle-income countries, and improving maternal and neonatal health is often a central goal. As yet, there have been few reviews of such programmes and their impact on maternal health. The US Government Evidence Summit on Enhancing Provision and use of Maternal Health Services through Financial Incentives was convened on 24-25 April 2012 to address this gap. This article, the final in a series assessing the effects of financial incentives\u2014performance-based incentives (PBIs), insurance, user fee exemption programmes, conditional cash transfers, and vouchers\u2014summarizes the evidence and discusses issues of context, programme design and implementation, cost-effectiveness, and sustainability. We suggest key areas to consider when designing and implementing financial incentive programmes for enhancing maternal health and highlight gaps in evidence that could benefit from additional research. Although the methodological rigor of studies varies, the evidence, overall, suggests that financial incentives can enhance demand for and improve the supply of maternal health services. Definitive evidence demonstrating a link between incentives and improved health outcomes is lacking; however, the evidence suggests that financial incentives can increase the quantity and quality of maternal health services and address health systems and financial barriers that prevent women from accessing and providers from delivering quality, lifesaving maternal healthcare

Monitoring and Evaluating Progress towards Universal Health Coverage in Ethiopia

<p>Monitoring and Evaluating Progress towards Universal Health Coverage in Ethiopia</p

Trends in maternal mortality ratios (maternal deaths per 100,000 live births).

<p>Sources: <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001696#pmed.1001696-Central1" target="_blank">[16]</a>–<a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001696#pmed.1001696-Central3" target="_blank">[18]</a>.</p

Trends in childhood mortality rates (deaths per 1,000 live births).

<p>Sources: <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001696#pmed.1001696-Central1" target="_blank">[16]</a>–<a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001696#pmed.1001696-Central3" target="_blank">[18]</a>.</p

Did the strategy of skilled attendance at birth reach the poor in Indonesia?

OBJECTIVE: To assess whether the strategy of "a midwife in every village" in Indonesia achieved its aim of increasing professional delivery care for the poorest women. METHODS: Using pooled Demographic and Health Surveys (DHS) data from 1986-2002, we examined trends in the percentage of births attended by a health professional and deliveries via caesarean section. We tested for effects of the economic crisis of 1997, which had a negative impact on Indonesia’s health system. We used logistic regression, allowing for time-trend interactions with wealth quintile and urban/rural residence. FINDINGS: There was no change in rates of professional attendance or caesarean section before the programme’s full implementation (1986-1991). After 1991, the greatest increases in professional attendance occurred among the poorest two quintiles - 11% per year compared with 6% per year for women in the middle quintile (P = 0.02). These patterns persisted after the economic crisis had ended. In contrast, most of the increase in rates of caesarean section occurred among women in the wealthiest quintile. Rates of caesarean deliveries remained at less than 1% for the poorest two-fifths of the population, but rose to 10% for the wealthiest fifth. CONCLUSION: The Indonesian village midwife programme dramatically reduced socioeconomic inequalities in professional attendance at birth, but the gap in access to potentially life-saving emergency obstetric care widened. This underscores the importance of understanding the barriers to accessing emergency obstetric care and of the ways to overcome them, especially among the poor