IMMPACT

Population Reference Bureau

English

Aberdeen University Research

BackgroundIn 2003, in an effort to improve maternal health and survival, the government of Ghana implemented a new policy that removed delivery fees in health facilities in the four most-deprived regions of the country. The govern-ment hoped more births would take place in facilities and in the hands of skilled providers, rather than at home with less skilled or no help. Less than two years later, the government extended the policy to the rest of Ghana, removing delivery fees in all public, private, and mission facilities. Immpact evaluated how the delivery-fee-exemption policy affected utilisation and quality of services, and maternal health and survival. Studies were carried out in the Central and Volta regions to examine the implementa-tion of the policy; assess whether the removal of delivery fees led to more deliveries in health facilities; evaluate the consequences of the policy on health care and health outcomes; and quantify the effects on costs of removing delivery fees to households and the health system. FindingsThe delivery-fee-exemption policy increased utilisation of delivery services. Data from Ghana showed an increase in utilisation of delivery care services. In the Central region, facility-based deliveries increased by 12 percentage points and in the Volta region, by 5 percentage points between 2003 and 2005. Key informants, such as facility managers and health care workers, reported an increase in the number of facility deliveries while the fee-exemption policy was in place. Interviewees also reported that women sought care at facilities earlier in their labour, making it easier to manage complications. Evidence suggests that the number of maternal deaths in facilities continues to drop. Quality of services was poor and remained unchanged by the fee-exemption policy. Despite increases in utilisation, quality of care did not improve during the implementation of the policy. Overall quality of care was poor prior to the implementation of the delivery-fee-exemption policy and remained so after the new policy took effect. Among positive findings, although resources were stretched by the increase in number of clients, providers reported that needed drugs and supplies, such as delivery kits, were generally available. Quality of care was assessed through a review of delivery case records. For each delivery, selected labour and delivery care activities were categorised and scored, with a maximum score of 44. The figure shows a comparison of quality of care scores at health centres before and after the implementation of the delivery-fee-exemption policy. Evaluating Removal of Delivery Fees in GhanaRemoving financial barriers helps the poorest women access needed obstetric care.February 2007POPULATION REFERENCE BUREAUQuality of Care at Health Facilities Before and After Delivery-Fee-Exemption Policy, Total Mean Score, Central and Volta Regions, 2003 and 2005Note: The highest score possible was 44.Source: Immpact.Public16.4 16.29.817.414.110.88.8 8.7PrivateBefore policy took effectAfter policy took effectCentral VoltaPublic PrivateQuality of care:The primary challenge to quality of care was the magni-tude of the workload. About 88 percent of health care workers surveyed reported increased working hours following the introduction of the policy. All professional groups reported an increase in client numbers, ranging from seven more clients per nurse per week to 17 more clients for doctors, medical assistants, and midwives. Few of the health workers surveyed received financial incentives directly related to the delivery-fee-exemption policy (only 12 percent). Staff morale appeared to have been sustained by non-financial benefits. Health workers appreciated the opportunity to offer care to women who could not otherwise afford it. Transportation, cultural, social, and other financial  barriers remained and impeded access to skilled care. While removing fees for delivery care successfully increased utilisation of services, other barriers prevented some pregnant women from accessing skilled care. According to results from surveys of the community and health care providers, these barriers included: cost of transportation, medications, and supplies; long distances to health facilities; cultural and social barriers; custom of using traditional birth attendants; and poor quality of care.Implementation of the delivery-fee-exemption policy was successful but lack of funding compromised  sustainability. The delivery-fee-exemption policy was successfully intro-duced and implemented, but due to lack of funds, this policy was continued unevenly. Some facilities eventually reverted to charging for delivery services. Analyses of how money was allocated and used for delivery care suggested that while funds were available from the government, facilities increased their revenue, with reim-bursements from the government exceeding losses from user fees foregone. Once funds ran out, however, facilities accrued debts and eventually abandoned the policy. Recommendations • Quality of care must be addressed to improve maternal health and survival.• Remove delivery fees to allow more women and families to choose delivery in health care facilities. However, for large gains to be made in reducing maternal deaths, more than just finan-cial barriers must be eliminated. Special efforts to remove other barriers such as long distances over difficult roads, transportation and drug costs, and cultural factors need attention. • Steady and secure funding must be identified  to ensure the sustainability of delivery-fee- exemption policies. Clear management systems must be set up to monitor funding streams and to facilitate timely reimbursements to facilities. There is an urgent need to budget adequately for imple-mentation and improve monitoring of cash flow to regions to strengthen the entire delivery-fee-exemp-tion policy. For more information on Immpact, please visit www.immpact-international.org.

Evaluating removal of delivery fees in Ghana : removing financial barriers helps the poorest women access needed obstetric care

https://aura.abdn.ac.uk/bitstream/2164/210/1/Evaluating%20Removal%20of%20Delivery%20Fees%20in%20Ghana.pdf

Evaluating removal of delivery fees in Ghana : removing financial barriers helps the poorest women access needed obstetric care

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