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The Experience of Ghana in Implementing a User Fee Exemption Policy to Provide Free Delivery
Care
Author(s): Sophie Witter, Daniel Kojo Arhinful, Anthony Kusi and Sawudatu Zakariah-Akoto
Source: Reproductive Health Matters, Vol. 15, No. 30, Maternal Mortality and Morbidity: Is
Pregnancy Getting Safer for Women? (Nov., 2007), pp. 61-71
Published by: Reproductive Health Matters (RHM)
Stable URL: http://www.jstor.org/stable/25475335
Accessed: 02-10-2015 14:16 UTC
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HealthMatters. I reproductive
? 2007Reproductive
All rightsreserved. HEALTH
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a User Fee
The Experienceof Ghana in Implementing
ExemptionPolicy to Provide Free DeliveryCare
AnthonyKusi,c Sawudatu Zakariah-Akotod
SophieWitter,3Daniel Kojo Arhinful,b
a Research Fellow, IMMPACT,Universityof Aberdeen, Aberdeen, Scotland.
E-mail: sophiewitter@blueyonder.co.uk
b Research Fellow, Noguchi Memorial Instituteof Medical Research, College of
Health Sciences, Universityof Ghana, Accra, Ghana
c Researcher, IMMPACT,Noguchi Memorial Instituteof Medical Research, University
of Ghana, Accra, Ghana
Abstract: In resource-poor countries, the high cost of user fees fordeliveries limitsaccess to skilled
attendance, and contributes tomaternal and neonatal mortality and the impoverishmentof
vulnerable households. A growing number of countries are experimentingwith differentapproaches
to tackling financial barriers tomaternal health care. This paper describes an innovative scheme
introduced in Ghana in 2003 to exempt all pregnant women frompayments for delivery, in which
public, mission and private providers could claim back lost user fee revenues, according to an agreed
tariff.The paper presents part of the findingsof an evaluation of thepolicy based on interviewswith
65 key informants in the health system at national, regional, district and facility level, including
policymakers,managers and providers. The exemption mechanism was well accepted and
appropriate, but therewere importantproblems with disbursing and sustaining the funding,and
with budgeting and management Staff workloads increased as more women attended, and levels of
compensation forservices and staffwere important to the scheme's acceptance. At the end of 2005,
a national
health
insurance
scheme,
to include
intended
full maternal
health
care
cover,
was
starting up in Ghana, and itwas not yet clear how the exemptions scheme would fit into it
?2007
Reproductive Health Matters. All rights reserved.
Keywords: delivery care, user fees, health financing,Ghana
to women delivering in health
include poor quality services,
negative attitudes of health workers, dis
tance to facilities and cultural preferences.1'2
Financial barriers have also been important,
but there have been relatively few studies of
whether and how changing fees influences
BARRIERS
facilities
women's
what
uptake
of maternity
services
and
at
cost.
sustainable
cussions
focus
on
basis
continues.
the
complementary
Current
dis
measures
fees
is carried
out
successfully.5'6
61
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5 Witter
et al / Reproductive
Health
Background
in urban
areas,
33%
in rural);
31%
by
tra
Comprehensive
emergency
obstetric
care
Matters
2007;!5(30):61-71
to women's
income.10
Problems
such
as
reduction.14
assisted
to type of delivery
according
or caesarean
and
section)
normal,
(e.g.
type
of facil
of
care
assessments.
These
were
com
pleted in 2006.16
The policy of user fee exemptions is now to
some extent being superseded by a new National
Health Insurance system, which has reached
effective coverage of just under 20% of the
I population.17 This provides protection against
62
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S Witter
et al / Reproductive
Health
Methods
For the evaluation two regions were chosen:
one of the four regions to join the exemption
scheme first (Central) and the other from the
more recent wave
(Volta). Six focus districts
from each region (roughly half of the districts in
each region) were chosen, and matched for pop
ulation size, poverty status, urban profile and
health infrastructure.15
The 65 key informant interviews were con
ducted from September-December
2005. The
key informants included key stakeholders in the
Ministry of Health, Ghana Health Services, mis
sion sector and development partners9; Regional
Directors of Health Services, Senior Medical
Officers, regional hospital directors and admin
istrators,and regional accountants7; and District
Directors of Health Services and senior public
health staff,District Assembly staff and accoun
tants.32
sample
of
in-charges,
matrons
and
of stratified
random
process
sampling,
sent each
of the six focus districts
and
to repre
to cover
homes
and mission
clinics.
questionnaire.
The
questions
covered:
and
failures,
implementation,
allo
current
implementation,
adequacy
Matters
2007,15(30):61-71
Findings
Overall perceptions
There was generally a positive reception of the
free delivery policy as an effective approach to
an important problem, which allowed for early
reporting and better handling of complications.
Stakeholders within the health system found the
administration of the scheme manageable
and
there was reasonable consistency in the inter
pretation of the policy. These informants were
only able to provide weak evidence on commu
nity perceptions, but theirview was that commu
nities were both informed and enthusiastic. The
scheme was publicised through meetings with
traditional rulers, broadcasts and durbars (public
meetings) at churches and other public places.
The trends in utilisation - both up, when the
63
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S Witter
scheme was
stopped
et al / Reproductive
suggested
were
Health
it
cost-aware
main
constraints,
which
of funding
were
causing
Matters
con
2007;15(30):61-71
were
it was
in arrears,
not
clear
whether
not
available.
In Volta,
concerns
were
flows
was
also
needed.
This
was
par
64
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S Witter
et al / Reproductive
Health
ity number
size.
sections
were
paid
at
less
than
the
well
above
previously
user
charged
fees.
up
its own
reimbursement
rates,
materials
used,
rather
than
at fixed
rates.
There
Matters
2007;!5(30):61-71
Tiredness
and
overload
were
reported,
with
the quality
of services,
e.g. with
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S Witter
et al / Reproductive
Health
already
was
payments
apparent,
mixed.
evidence
on
infor
Referrals
Given the shortage of medical and nursing staff
in Ghana, referrals are often the result of the
absence of a key member of staff or of key sup
plies, such as blood. Under the exemptions policy,
women presenting at health centres and district
hospitals were eligible for delivery fee exemp
tions,but attendance at regional hospitals required
a referralto qualify. However, therewas no formal
system for splitting the reimbursement payments
between facilities when women were referred.
This led to concerns that lower level facilities
would fail to referwomen at appropriate times
in order not to lose the income from their case, as
the facilitywhich finally carried out the delivery
got the full reimbursement. This was denied by
health staff,who pointed tomaternal death audits
as one way ofmonitoring this tendency. In prac
tice, some degree of flexibility about reimburse
ment was found, such that direct costs such as
transport, incurred by lower level facilities, could
be claimed back, even if the delivery eventually
took place elsewhere.
In Central, exemption funds were held by
districts, and the regional hospital was experi
encing difficulties getting reimbursements from
the districts. In Volta, the system operated dif
ferently, and 5% of funds were top-sliced to a
separate
account
in advance
to pay
for referrals.
still
Matters
2007;15(30):61-71
offered.
to come
in early,
so
that
complica
there
were
86
caesarean
in
sections
of caesareans.
For
Central
region
as
66
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5 Witter
et al / Reproductive
Health
Recommendationsby informants
Some
concern
the main
was
the
sus
it takes
such
as prayer
camps
or scans
Scheme
cover.
2007;15(30):61-71
years."
for other
Matters
Formal
sector
workers
were
auto
Discussion
Ghana's
nant
scheme,
women
which
and
provides
free
under-fives,
care
has
for preg
increased
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5 Witter
et al / Reproductive
Health
and
caesarean
section.
The
total
pay
Matters
2007;!5(30):61-71
care.22
Ghana's
suggests that where
experience
facilities are understaffed, as in much of sub
Saharan Africa, they should be closely involved
in the development of policies such as these
and a package of incentives provided for staff
to deliver quality care. The health worker survey
in this evaluation found that although very few
direct financial incentives were provided as part
of the delivery exemption policy, the overall
increase in pay as part of wider pay reforms in
the public sector compensated for increased
hours ofwork for differenttypes of staff.28
Qualitative work with midwives and communi
ties suggests that comprehension of the policy was
not always strong,29 highlighting the need for
clear, simple designs and better communication.
Ghana, 2003
68
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5 Witter
et al / Reproductive
Health Matters
on
and
the whole,
poor,16
e.g.
Ghana's
experience
corroborates
sector,
private
midwives
and
even,
in some
Conclusion
rou
2007;15(30):61-71
Acknowledgements
We would like to acknowledge the support of
j the research team in the Noguchi Institute for
jMedical Research, University of Ghana, and the
University of Aberdeen, in particular Margaret
Armar-Klemesu, the Country Technical Partner
leader. Thanks also to the key informantsfor their
generous donation of time to share their views
with us, and also to those who commented on
the paper, especially Tim Ensor. This work was
j
as
undertaken
part
of
an
international
research
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Resume
Dans les pays pauvres, le montant eleve des
contributions demandees aux patientes pour les
accouchements
limite faeces a des soins de
en
tout
contribuant a la mortalite
qualite,
maternelle et neonatale et a l'appauvrissement
des menages
Un
vulnerables.
nombre
croissant
de pays experimented
differentes methodes
aux soins de
lever
les
financiers
obstacles
pour
sante maternelle. Un projet novateur, introduit
au Ghana en 2003, exonerait toutes les femmes
enceintes du paiement des accouchements et
prevoyait que les praticiens publics, prives et des
missions pouvaient recuperer leurs honoraires
perdus,
L'article
conformement
presente
une
un
partie
convenu.
bareme
des
conclusions
de sante
aux
niveaux
national,
regional,
Le mecanisme
et etait
a ete bien
d'exoneration
satisfaisant,
mais
il connaissait
le projet d'exoneration
encore
claire.
s'y adapterait
n'etait
Matters
2007;15(30):61-71
Resumen
En los paises con pocos recursos, el alto costo de
las tarifas por partos limita el acceso a asistencia
calificada y contribuye a la mortalidad materna
y neonatal y al empobrecimiento de hogares
vulnerables. En un creciente mimero de paises se
esta experimentando con diferentes estrategias
para afrontar los obstaculos financieros a los
servicios de salud materna. En este articulo se
describe un plan innovador presentado en
Ghana en 2003 para eximir a todas las mujeres
embarazadas
de
pagos
por
parto,
mediante
no
integraria
era
claro
a este.
como
el plan
de
exenciones
se
71
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