Presentation on theme: "Financing Maternal Health Services: An overview of approaches"— Presentation transcript:
1Financing Maternal Health Services: An overview of approaches Laurel Hatt, PhDHealth Systems 20/20Abt Associates Inc.September 9, 2010Global Health Council
2Outline Why does maternal health financing matter? Key approaches and case studiesBig picture conclusions
3Why does health financing matter for maternal health? Raising money for eclampsia care in Burkina Faso:“My father asked for part of it at the mosque, and my mother also asked for some and then we added our 5,000 F [savings]... my mother got 1,000 F from one person and 1,000 from another, 1,500 from yet another. We had a bit of maize that we sold. I had three cloths and I sold these and added it all up and had 15,000 F, which we went to give [to the hospital].”Storeng K, Baggaley R, Ganaba R, Ouattara F, Akoum M, Filippi V. (2008). Paying the price: The cost and consequences of emergency obstetric care in Burkina Faso. Social Science & Medicine 66:
4Why does health financing matter for maternal health? Access to safe motherhood servicesBarriers – “3 delays”Desire to avoid costs delayed decision to seek careFinding money for transport delayed arrival to facilityRaising money to pay for hospital care delayed admission to hospitalHome births have no transportation costs, lower time costs, fewer fees for care providers, no unofficial payments, and are potentially less burdensome to the family than facility-based births. How can we change the incentives?
5Why does health financing matter for maternal health? Financial protectionCatastrophic expendituresMaternal care can be very expensive, especially if there are complicationsRaising money for care can create future risks (going into debt, selling assets, cutting spending on essentials)Impoverishment – costs can force a family into povertyEconomic, social, health consequences for the familyNormal delivery: Direct costs range from 1-5% of annual household expendituresDoesn’t include transport, time costs, hotel, foodComplicated delivery: 5-34% of household expendituresWhat makes up those costs?Transportation (can be up to 50% of total)Service delivery (room charge, provider fees, drugs, supplies, lab tests, food)Drugs can be 35-55% of service chargesInformal or under-the-table paymentsOpportunity costs of time lost – for the woman, for her caregivers
6So what are the options? Fee exemptions Insurance For deliveriesFor C-sectionsInsuranceCommunity-based health insuranceNational/social health insuranceDemand-side financingVouchersConditional cash transfers
8User fee exemptionsUser fees can be a significant barrier to access, especially for the poorDemand for delivery care goes down after fees addedUser fees hurt the poor moreBut user fees can represent a substantial proportion of health financing at the facility level (15-40%)May be especially important for covering recurrent costs – supplies, drugs – and avoiding stock-outsProvide “top-ups” to underpaid staffPoor: represent a larger portion of their incomeDemand for normal delivery care goes down most
9User fee exemptions: Ghana User fees for deliveries were abolished overResults:Higher skilled attendance ratesIncreases greatest among poorer quintiles, less educated womenLower out-of-pocket (OOP) paymentsRich benefit more than poor in proportionate termsDecrease in incidence of catastrophic paymentsEspecially for C-sectionsEspecially among the poorestHIPC Debt relief funds were channeled to districts to reimburse public and private facilities12% -- Central5% -- Volta – more rural areaCatastrophic expenditures: Delivery expenditures >2.5% of income(decrease of 22% [richest] vs. 13% [poorest])
10User fee exemptions: Ghana Source: Witter et al. (2009), Providing free maternal care: Ten lessons from an evaluation of the national delivery exemption policy in Ghana. Global Health Action.
11User fee exemptions: Ghana Challenges:Quality of care problemsSome decreases in quality of care measured; overall facility quality is very lowFunding shortagesGovernment did not obtain debt relief funds in 2005Severe under-funding as exemptions were extended beyond pilot regionsFees were reinstated in many areasFacilities built up debt waiting for reimbursement for care already providedQOC assessment scores significantly decreased in Volta region – quality either unchanged or decreasedMorestin F & Ridde V (2009). The abolition of user fees for health services in Africa Lessons from the literature. Université de Montréal.“In Ghana, for as long as the compensatory funds were available, administrators of health facilities were relieved to no longer have to pursue women unable to pay for their deliveries. However, as the compensatory funds became inadequate, health facilities became indebted to their suppliers, to the point where some had to reinstate payment from women for deliveries.”
12Fee exemptions for C-sections: Mali Free C-section policy announced July 2005Normal deliveries still have charges (up to $14)Facilities compensated for lost revenueKits with drugs, supplies and other consumables for C-sectionsReimbursed on actual costs of hospital stay: Up to $60 for each caseVery low C-section rate in Mali: 1.6% (DHS 2006)MMR between 400 and 600Under 5% indicates low access to obstetric care to reduce maternal mortalityUnder 2% indicates extremely low accessIncluded cost of surgery, drugs, lab tests, and hospitalization; excluded transport, except to referral facility)
13Mali: Clear increase in C-section rates over time Source: Health Systems 20/20, Abt Associates13
14Fee exemptions for C-sections: Mali Use of C-sections more than doubled,But 2.33% rate is still very lowNo evidence of increase in unnecessary C-sectionsClear possibility of perverse incentivesChallenges:Financial and quality barriers to facility-based normal delivery care remainTransport barriers from villages to first-level facilitiesPoor communications and referrals systems between first and higher-level facilitiesOptimal rate: 5% to 15% (AMDD Working Group on Indicators 2004)Rates still less than 1% in several regionsPreliminary results indicate that the “free caesarean” policy is supported by health facility staff, andstaff shortages and supplies stockouts have not posed a major problem.However, four key issues contribute to limited access to institutional deliveries and caesarians despite the subsidy program:difficulties with travel from villages to first level facilities,poorly functioning communications and referral systems between first and higher level facilities,financial barriers to delivering in health facilities (deliveries are not free) andperceptions of low interpersonal quality of delivery care.
15Challenges with user fee exemptions Providers find ways to compensate for lost revenueCosts may be passed on or shifted to other services to make up the differencePoorer quality, unofficial fees patients may turn to private sectorMore stock-outs may mean consumers have to pay for drugs elsewhereNonfinancial barriers remain (incl. transportation)Targeting is difficultExempt everyone – rich benefit most?Exempt only the poor – how do you identify them? How to avoid stigmatization?“The more or less transitory problems having to do with quality of services (particularly shortages of medicines), excessive workload for health care workers, and patients turning to paid services when the free services are overloaded are not related to the abolition of fees as such. Rather, they are due to inadequate implementation; despite the laudable efforts of government, implementation has often been precipitous, the required resources poorly planned and not available, and follow-up lacking.”Morestin F & Ridde V (2009). The abolition of user fees for health services in Africa Lessons from the literature. Université de Montréal.
17Community-based health insurance Nonprofit schemes providing risk pooling to cover some portion of health care costsOften rooted in traditional solidarity mechanismsUsually emphasize participatory decision-making and managementMembership is voluntaryCommunity decides what services to coverUsually target the “informal sector,” those excluded from formal social protection systemsWest Africa – Senegal, Mali, Ghana, Benin, Guinea, CameroonEastern Africa – Rwanda, Ethiopia, TanzaniaChina
18Community-based health insurance: What works? Can improve access to health care, especially services highly valued by community (like delivery care)Can improve financial protection for groups excluded from traditional insuranceCan replace user fees, while maintaining fee revenue for health facilitiesIncreased emergency obstetric care (EmOC) coverage?Inventory of schemes in West Africa (2003) found that 55% included coverage for C-sectionDelivery care (esp. referral care) is one of the most commonly covered services by CBHI schemesPeople can seek care when they need it, and tend to seek care earlier– avoid stock-outs, reduce informal fees
19Community-based health insurance: What are the challenges? Low population coverage (with exception of Rwanda) – lots of pilots, not much scale-upTypical private insurance problems: small risk pools, adverse selectionManagement challenges – volunteer, unskilled staffLow revenue generation potential if all members are poor – often need subsidies to be sustainableConcept of insurance may be alien; people want “something” for their moneyEffective insurance requires real technical expertise
20Community-based health insurance: Mali Positive evidence:Pregnant women who were scheme members were more likely to have at least 4 ANC visits (58%) than non-members (35%)More likely to receive malaria prophylaxis (79% vs. 60%)More likely to sleep under an insecticide-treated net (60% vs. 35%) – promoted by the schemeNo evidence of increased skilled attendance ratesIn Mali, a process extending health insurance coverage has been envisioned, with components including workers in the formal and informal sectors as well as those who are financially unable to access health care. In collaboration with World Bank and the Ministerial Leadership Initiative (MLI), Health Systems 20/20 has already supported the Government of Mali to develop a CBHI strategic plan and five-year workplan for the informal sector.Source: Franco L, Simpara C, Sidibe O, Kelley A et al. (2006). Equity Initiative in Mali: Evaluation of the Impact of Mutual Health Organizations on Utilization of High Impact Services in Bla and Sikasso Districts in Mali. Partners for Health Reformplus, Abt Associates Inc., Bethesda, MD.
21National or social health insurance Pros: Can be comprehensiveUniversal insurance coverage with basic package of health services –including maternal servicesCan include coverage for normal and/or surgical delivery careCons: ComplicatedNeed functional tax collection systems, claims processing systems, effective/feasible provider payment mechanismsPolitically challenging to implementPotential cost escalation – how to control?Some low-income countries are experimenting and/or implementing:Ghana, Rwanda, India, Nigeria …National vs. social -- different funding and service provision arrangementsNational health insurance:Funded through general tax revenuesGovernment is the insurer, may directly provide servicesSocial health insurance:Funded through payroll taxes (like Social Security)Separate social security agency(ies) are the insurersContracts with public and private providers
22National health insurance: Ghana 2005: Ghana rolled out the National Health Insurance Scheme (NHIS)Goal: Universal coverage for basic servicesGoal: Financial protection from health care costsNo fees for maternal health careBy 2008: 61% of population enrolledWealthy much more likely to enroll than the poorConcerns about equity, cost escalation and financial sustainability70% of the population is exempt from premiumsMost funding comes from sales taxes (regressive)Goal: Universal coverage for basic servicesFunding: sales tax, payroll tax, registration fees and sliding scale premiums ($5-30/year)Top quintile almost 3 times as likely to enroll as poorest quintile70% are exempt from premiums53% of women who delivered in 2007 paid nothing
23National health insurance: Ghana HS20/20 impact evaluation ( ):Improved financial protection for maternal health care servicesOOP expenditures decreased for ANC, delivery careInsured women pay 1/6 of what uninsured payInstitutional delivery rates did not change (54.4% vs. 54.9%) WHY?Those most likely to enroll in health insurance were already more likely to deliver in a facilityPoor quality of care in facilitiesProblems reimbursing facilitiesNon-financial barriers remain – distance, cultural factorsSource: Sulzbach S, Chankova S, Hatt L et al. (2009). Evaluating the Effects of the National Health Insurance Act in Ghana: Final Report. Health Systems 20/20, Abt Associates Inc., Bethesda, MD.
24National health insurance: Ghana But: recently some more positive signs –2008: Pregnant women were exempted from NHIS premiums and registration fees2010 evaluation (draft*): Preliminary signs that NHIS enrollment is beginning to increase rates of skilled birth attendance and institutional delivery.Conclusions?May just take time for measurable impacts to occurMay need to specifically prioritize / emphasize / publicize MH benefits within the insurance programDesign, provider payment, operations, quality – all matter.Also:Ghana National Development Planning Commission survey (nationally representative, 2008) found that 70% of deliveries in past 12 months took place in health facilities, compared with the MICS 2006 results (50% of deliveries).*Agar Brugiavini and Noemi Pace (2010 draft), Extending Health Insurance: Effects of the National Health Insurance Scheme in Ghana. Ca’ Forscari University of Venice Department of Economics.
26Why demand-side financing? Traditional (supply-side) financing not very successful in increasing access of poorest women to quality careInput-based subsidies may go to the better off (leakage)The poor face more demand-side barriers – service costs, transport costs, distance from skilled providers, lack of knowledge or information about servicesDemand-side financing: Get the money (and services) directly to the people who need them.Supply side financing: (government subsidies are paid to providers)
27Vouchers and Conditional Cash Transfers Vouchers: subsidies paid directly to a consumer – like a couponCan subsidize a specific health care service (ANC visit), or related services or goods (drugs, transportation, food)Can target to specific populationsConditional cash transfers (CCTs): cash payments to individuals or households, contingent upon use of particular servicesPayment is made after the desired behavior is carried out – although service use may increase, access does not necessarily increaseCan be from public or private sourceEntitles consumer to free or discounted service(s) from approved providers
28Vouchers and CCTs: Bangladesh Pilot program – Vouchers for ANC, delivery care, emergency and postnatal care (PNC); cash incentive for delivery with qualified provider; transportation reimbursementDistributed to pregnant women by health field workersCombined with some supply-side incentives to providers2009 evaluation* results:45 percentage point higher skilled attendance rates in intervention vs. control areasSignificantly higher rates of ANC, institutional deliveries, PNCNo difference in C-sectionsSignificantly lower OOP expendituresLaying the administrative groundwork for large-scale health insurance schemes (accreditation, quality assurance, claims processing)*Hatt, Laurel, Ha Nguyen, Nancy Sloan, Sara Miner, Obiko Magvanjav, Asha Sharma, Jamil Chowdhury, Rezwana Chowdhury, Dipika Paul, Mursaleena Islam, and Hong Wang. February Economic Evaluation of Demand-Side Financing (DSF) for Maternal Health in Bangladesh. Bethesda, MD: Review, Analysis and Assessment of Issues Related to Health Care Financing and Health Economics in Bangladesh, Abt Associates Inc.
29Vouchers – AdvantagesTarget specific groups or areas – get access directly to the people who need it mostDemand creation – simply by distributing vouchers with information about servicesCan cover transport costs as well as service costsMay improve quality and reduce costs – by making providers compete for voucher customers29
30Vouchers – Challenges May have high administrative costs Targeting can be difficult and costlySudden increase in demand can overwhelm facilitiesCould skew service provision towards voucher services, away from other valued prioritiesSustainability? (generally donor-financed thus far)30
31Conditional cash transfers – Advantages and Challenges Consumers can use the cash as they see fit – independence, poverty reductionCould result in overall improvement in welfare, not just health statusVerification of conditions can be expensive, time-consumingOpportunities for corruption/fraudHow do people use the money?Example: JSY in IndiaLancet article on JSY program in India –
33So what can financing interventions do to improve maternal health? Increase skilled attendance at deliveryProvide access to EmOCPrevent delivery care and EmOC from causing catastrophic expendituresReduce financial barriers to transportation
34…and what can’t they do? Easily reach the poorest of the poor Erase problems with insufficient infrastructure and poor quality servicesEradicate geographical and cultural barriers, which are often more intractable than financial barriers
35Health systems strengthening is key Success of a financing scheme is not just based on the financing mechanism, but on all elements of health system functioningAccessible health facilitiesHuman resources – staff, skills, motivationQuality of careLogistics, supplies, equipment, infrastructurePolitical will and leadershipCultural shifts / behavior change
36Thank you! Laurel_Hatt@abtassoc.com Reports related to this presentation available at