Financing Maternal Health Services: An overview of approaches

1. Financing Maternal Health Services:An overview of approaches Laurel Hatt, PhD Health Systems 20/20 Abt Associates Inc. September 9, 2010 Global Health Council

2. Outline • Why does maternal health financing matter? • Key approaches and case studies • Big picture conclusions

3. Why 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: 545-557.

4. Why does health financing matter for maternal health? • Access to safe motherhood services • Barriers –“3 delays” • Desire to avoid costs  delayed decision to seek care • Finding money for transport  delayed arrival to facility • Raising money to pay for hospital care  delayed admission to hospital

5. Why does health financing matter for maternal health? • Financial protection • Catastrophic expenditures • Maternal care can be very expensive, especially if there are complications • Raising money for care can create future risks (going into debt, selling assets, cutting spending on essentials) • Impoverishment – costs can force a family into poverty • Economic, social, health consequences for the family

6. So what are the options? • Fee exemptions • For deliveries • For C-sections • Insurance • Community-based health insurance • National/social health insurance • Demand-side financing • Vouchers • Conditional cash transfers

7. User fee exemptions

8. User fee exemptions • User fees can be a significantbarrier to access, especially for the poor • Demand for delivery care goes down after fees added • User fees hurt the poor more • But 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-outs • Provide “top-ups” to underpaid staff

9. User fee exemptions: Ghana • User fees for deliveries were abolished over 2003-2005 Results: • Higher skilled attendance rates • Increases greatest among poorer quintiles, less educated women • Lower out-of-pocket (OOP) payments • Rich benefit more than poor in proportionate terms • Decrease in incidence of catastrophic payments • Especially for C-sections • Especially among the poorest

10. User 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.

11. User fee exemptions: Ghana Challenges: • Quality of care problems • Some decreases in quality of care measured; overall facility quality is very low • Funding shortages • Government did not obtain debt relief funds in 2005 • Severe under-funding as exemptions were extended beyond pilot regions • Fees were reinstated in many areas • Facilities built up debt waiting for reimbursement for care already provided

12. Fee exemptions for C-sections: Mali • Free C-section policy announced July 2005 • Normal deliveries still have charges (up to $14) • Facilities compensated for lost revenue • Kits with drugs, supplies and other consumables for C-sections • Reimbursed on actual costs of hospital stay: Up to $60 for each case

13. Mali: Clear increase in C-section rates over time Source: Health Systems 20/20, Abt Associates

14. Fee exemptions for C-sections: Mali • Use of C-sections more than doubled, 2005-2009 • But 2.33% rate is still very low • No evidence of increase in unnecessary C-sections • Clear possibility of perverse incentives • Challenges: • Financial and quality barriers to facility-based normal delivery care remain • Transport barriers from villages to first-level facilities • Poor communications and referrals systems between first and higher-level facilities

15. Challenges with user fee exemptions • Providers find ways to compensate for lost revenue • Costs may be passed on or shifted to other services to make up the difference • Poorer quality, unofficial fees  patients may turn to private sector • More stock-outs may mean consumers have to pay for drugs elsewhere • Nonfinancial barriers remain (incl. transportation) • Targeting is difficult • Exempt everyone – rich benefit most? • Exempt only the poor – how do you identify them? How to avoid stigmatization?

16. Insurance

17. Community-based health insurance • Nonprofit schemes providing risk pooling to cover some portion of health care costs • Often rooted in traditional solidarity mechanisms • Usually emphasize participatory decision-making and management • Membership is voluntary • Community decides what services to cover • Usually target the “informal sector,” those excluded from formal social protection systems

18. Community-based health insurance: What works? • Can improve access to health care, especially services highly valued by community (like delivery care) • Can improvefinancial protection for groups excluded from traditional insurance • Can replace user fees, while maintaining fee revenue for health facilities • Increased emergency obstetric care (EmOC) coverage? • Inventory of schemes in West Africa (2003) found that 55% included coverage for C-section

19. Community-based health insurance: What are the challenges? • Low population coverage (with exception of Rwanda) – lots of pilots, not much scale-up • Typical private insurance problems: small risk pools, adverse selection • Management challenges – volunteer, unskilled staff • Low revenue generation potential if all members are poor – often need subsidies to be sustainable • Concept of insurance may be alien; people want “something” for their money

20. Community-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 scheme • No evidence of increased skilled attendance rates 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.

21. National or social health insurance • Pros: Can be comprehensive • Universal insurance coverage with basic package of health services –including maternal services • Can include coverage for normal and/or surgical delivery care • Cons: Complicated • Need functional tax collection systems, claims processing systems, effective/feasible provider payment mechanisms • Politically challenging to implement • Potential cost escalation – how to control? • Some low-income countries are experimenting and/or implementing: • Ghana, Rwanda, India, Nigeria …

22. National health insurance: Ghana • 2005: Ghana rolled out the National Health Insurance Scheme (NHIS) • Goal: Universal coverage for basic services • Goal: Financial protection from health care costs • No fees for maternal health care • By 2008: 61% of population enrolled • Wealthy much more likely to enroll than the poor • Concerns about equity, cost escalation and financial sustainability • 70% of the population is exempt from premiums • Most funding comes from sales taxes (regressive)

23. National health insurance: Ghana • HS20/20 impact evaluation (2004-2007): • Improved financial protection for maternal health care services • OOP expenditures decreased for ANC, delivery care • Insured women pay 1/6 of what uninsured pay • Institutional 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 facility • Poor quality of care in facilities • Problems reimbursing facilities • Non-financial barriers remain – distance, cultural factors Source: 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.

24. National health insurance: Ghana • But: recently some more positive signs – • 2008: Pregnant women were exempted from NHIS premiums and registration fees • 2010 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 occur • May need to specifically prioritize / emphasize / publicize MH benefits within the insurance program • Design, provider payment, operations, quality – all matter. *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.

25. Demand-side financing

26. Why demand-side financing? • Traditional (supply-side) financing not very successful in increasing access of poorest women to quality care • Input-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 services • Demand-side financing: Get the money (and services) directly to the people who need them.

27. Vouchers and Conditional Cash Transfers • Vouchers: subsidies paid directly to a consumer – like a coupon • Can subsidize a specific health care service (ANC visit), or related services or goods (drugs, transportation, food) • Can target to specific populations • Conditional cash transfers (CCTs): cash payments to individuals or households, contingent upon use of particular services • Payment is made after the desired behavior is carried out – although service use may increase, access does not necessarily increase

28. Vouchers and CCTs: Bangladesh • Pilot program – Vouchers for ANC, delivery care, emergency and postnatal care (PNC); cash incentive for delivery with qualified provider; transportation reimbursement • Distributed to pregnant women by health field workers • Combined with some supply-side incentives to providers • 2009 evaluation* results: • 45 percentage point higher skilled attendance rates in intervention vs. control areas • Significantly higher rates of ANC, institutional deliveries, PNC • No difference in C-sections • Significantly lower OOP expenditures *Hatt, Laurel, Ha Nguyen, Nancy Sloan, Sara Miner, Obiko Magvanjav, Asha Sharma, Jamil Chowdhury, Rezwana Chowdhury, Dipika Paul, Mursaleena Islam, and Hong Wang. February 2010. 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.

29. Vouchers – Advantages • Target specific groups or areas –get access directly to the people who need it most • Demand creation – simply by distributing vouchers with information about services • Can cover transport costs as well as service costs • May improve quality and reduce costs – by making providers compete for voucher customers

30. Vouchers – Challenges • May have high administrative costs • Targeting can be difficult and costly • Sudden increase in demand can overwhelm facilities • Could skew service provision towards voucher services, away from other valued priorities • Sustainability? (generally donor-financed thus far)

31. Conditional cash transfers –Advantages and Challenges • Consumers can use the cash as they see fit – independence, poverty reduction • Could result in overall improvement in welfare, not just health status • Verification of conditions can be expensive, time-consuming • Opportunities for corruption/fraud • How do people use the money? • Example: JSY in India

32. Lessons learned

33. So what can financing interventions do to improve maternal health? • Increase skilled attendance at delivery • Provide access to EmOC • Prevent delivery care and EmOC from causing catastrophic expenditures • Reduce 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 services • Eradicate geographical and cultural barriers, which are often more intractable than financial barriers

35. Health systems strengthening is key • Success of a financing scheme is not just based on the financing mechanism, but on all elements of health system functioning • Accessible health facilities • Human resources – staff, skills, motivation • Quality of care • Logistics, supplies, equipment, infrastructure • Political will and leadership • Cultural shifts / behavior change

36. Thank you!Laurel_Hatt@abtassoc.com Reports related to this presentation available at www.healthsystems2020.org