BackgroundBurkina Faso, like many low and middle income countries, has been taking a range of actions to address its poor maternal and neonatal health indicators. In 2006 the government introduced an innovative national subsidy scheme for deliveries and emergency obstetric care in public facilities. This article reports on a complex evaluation of this policy, carried out 5 years after its introduction, which examined its effects on utilisation, quality of care, equity and the health system as a whole, as well as its cost and sustainability.MethodsThe evaluation was carried out in six purposively selected districts, as well as at national level, using a case study approach. Data sources included: national and district routine and survey data, household interviews with women who had recently given birth, data extraction from hospital and medical records, and key informant and health worker interviews.ResultsThe underlying secular trend of a 1 % annual increase in the facility-based delivery rate (1988–2010) was augmented by an additional 4 % annual increase from 2007 onwards (after the policy was introduced), especially in rural areas and amongst women from poor households. The absence of baseline quality of care data made it difficult to assess the impact of the policy on quality of care, but hospitals with the best level of implementation of the subsidy offered higher quality of care (as measured by health care near-misses), so there is no evidence of a negative impact on quality (as is often feared). Similarly, there is little evidence of unintended negative effects on untargeted services. Household payments for facility-based deliveries have reduced significantly, compared with payments before the policy, and the policy as a whole is affordable, costing about 2 % of total public health expenditure.Concerns include that the amounts paid by households are higher than the rates set by the policy, and also that 7 % of households still say that they cannot afford to pay. Wealthier women have higher utilisation of services, as before, and the policy of fully exempting indigents is not being put into practice.ConclusionsThese findings highlight the importance of maintaining the subsidy policy, given the evidence of positive outcomes, but they also point out areas where attention is needed to ensure the poor and most vulnerable population benefit fully from the policy.
Abstractbackground The Free Deliveries and Caesarean Policy (FDCP) entitles all women in Morocco to deliver free of charge within public hospitals. This study assesses the policy's effectiveness by analysing household expenditures related to childbirth, by delivery type and quintile.methods Structured exit survey of 973 women in six provinces at five provincial hospitals, two regional hospitals, two university hospitals and three primary health centres with maternity units.results Households reported spending a median of US$ 59 in total for costs inside and outside of hospitals. Women requiring caesareans payed more than women with uncomplicated deliveries (P < 0.0001). The median cost was US$45 for a uncomplicated delivery, US$50 for a complicated delivery and US$65 for a caesarean section. The prescription given upon exiting the hospital comprised 62% of the total costs. Eighty-eight per cent of women from the poorest quintiles faced catastrophic expenditures. The women's perception of their hospital stay and the FDCP policy was overwhelmingly positive, but differences were noted at the various sites.conclusion The policy has been largely but not fully effective in removing financial barriers for delivery care in Morocco. More progress should also be made on increasing awareness of the policy and on easing the financial burden, which is still borne by households with lower incomes.
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.
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