Community and Health Provider Perspectives on Free Maternal and Child Health Services in Enugu, Nigeria

1. Removal of user fees for maternal and child health services in Enugu, South East Nigeria: Experiences of the community and Health care providers Benjamin SC Uzochukwu, OgoamakaChukwuogoObinnaOnwujekwe, . Health Policy Research Group, College of Medicine, University of Nigeria, Enugu-campus

2. Enugu state in south East Nigeria launched free maternal and child health (MCH) services in 2007. The programme is for all pregnant women to have free antenatal, delivery and post natal services including laboratory tests and blood transfusions. Children under 5 receive free medical treatment Introduction

3. Objectives • To determine the experiences and the perceptions of the community and health care providers on the removal of user fees for the MCH services

4. Methods • Cross sectional descriptive study • Exit interviews with 150 WRA from 10 health centers to elicit information on their awareness, attitude, utilization and factors affecting utilization of MCH services and willingness to continue use of this service. • Questionnaire interview with 50 healthcare providers from 10 health centers • In-dept interviews with 10 heads of health centers

5. Results (Consumers) • A majority (62.6%) of the women were aged between 21 and 30 years • Most had one form of formal education or the other. • High awareness of free MCH services (86%)

6. Service utilization • ANC services most utilised (55%), • Immunization services (47.3%), • Nutritional education (35.3%) • Growth monitoring (32%). • Family planning services were the least utilized (12%)

7. Payment for services • 80% of respondents said they accessed these services absolutely free of charge • 20% paid for services like ANC, delivery, family planning and immunization

8. Waiting Time • 28.7% of the respondents were able to receive medical care within 30 minutes of arrival • 33% waited between 30 minutes to an hour • 32% waited between 1 to 3 hours • Only very few 9% experienced a waiting time of more than 3 hours.

9. Receipt of prescribed drugs • 23% of respondents received all prescribed drugs • 48% of respondents received some of the prescribed drugs • 29% received no drugs.

10. Factors affecting utilization • lack of approval from spouse, • inadequate skilled personnel, • long waiting time • distance to the health facility.

11. Willingness to continue use of services • 84.7% would continue to utilize the services rendered at the health centre because: • services were free 33.1%, • easily accessible 26.0% • drugs were available 19.7% • 15.3% would not continue because: • Required services not available 43.5% • No drugs 30.4% • Delayed attention 17.4% • Distance 8.7%

12. Results: Health Workers Perspective • 96% of health workers opined that the MCH services were absolutely free • From health workers perspective, treatment of under 5s (94%), ANC (76%) and delivery services (68%) were the most frequently used services

13. Although the health workers were receptive of the free services, they opined that their workload had increased without any corresponding increase in their remuneration • that patients were making unnecessary visits to the health facilities and demand on drugs (moral hazard). Hence drug demand does not match supply.

14. Conclusions • Removal of user fees for MCH services have enhanced utilization of health services. • However this has greatly increased the workload of health providers and consumers still pay for MCH services. • Problems with drugavailability and waiting time

15. Recommendations • Provision of adequate personnel and infrastructure to cater for this increase • In the interim there should be better remuneration of health workers to motivate them to continue providing health services despite the increased workload. • There is also need to check the reported moral hazards that have been created by the removal of fees and mechanisms should be put in place to ensure that the free services are really free.