Removal of user fees for caesareans and under‐fives in northern Sudan: a review of policy implementation and effectiveness

Abstract

In 2008, the Government of Sudan launched a policy of free curative care for under-fives and caesareans. This paper presents the findings of a review of this policy, on the basis of research conducted in five focal states of northern Sudan in 2010. Policy implementation was assessed using four research tools: key informant interviews, exit interviews, a facility survey, and analysis of facility finances and the cost of the package of care. The findings point to important weaknesses in implementation, such as unclear specification of the exact target group and package of care and inadequate funding. Despite this, service utilisation appears to have responded, at least in the short term. The findings also highlight the urgent need for improved access to basic health care and financial protection against health care costs in northern Sudan (for those with and without national health insurance membership). This review contributes to the growing literature on the selective removal of user fees for priority services. It indicates the range of challenges to effective implementation (strategic, financial and organisational). Some of these are particular to Sudan, but many are shared, and indicate important lessons for improving access to and quality of care for women and children in Africa.

Impact of free delivery policy on utilization of maternal health services in county referral hospitals in Kenya

“…A policy of providing free care for caesareans and under-fives was launched in 2008 in northern Sudan. A review done two years later found that normal deliveries increased by 14% [ 18 ]. Ghana introduced a free maternal care initiative in 2008.…”

The free delivery and caesarean policy in Morocco: how much do households still pay?

“…We conducted interviews with women who gave birth, their husbands or their relatives who accompanied them to the hospital when they were about to leave the health facility. The interviews were conducted using a structured questionnaire that was used in Sudan for a similar survey . This questionnaire was adapted to the Moroccan context and then tested at a maternity hospital before being implemented in the different study sites.…”

Cesarean section in sub-Saharan Africa

“…Data from Demographic and Health Surveys conducted in ten SSA countries found that the policy change was consistent with an increase of 3.1 facility deliveries per 100 live births, which corresponds to a 5 % increase in facility deliveries, with no corresponding increase in the rate of CS [ 45 ]. In Sudan, the free care policy applied only to CS and not to vaginal delivery, but utilization of services still increased 14 %; authors noted, however, that this policy was implemented without the resources to support it, which still led to a significant portion of the cost being born by the woman and her family [ 46 ].…”