Background
Background on national policies
Benin
Burkina Faso
Mali
Morocco
Methods
Tool and findings section to which it contributes | Level | Key themes | Approach | |
---|---|---|---|---|
1 | Observation grid in meetings (B-SCALA)
Context and drivers
| Actors at the national, regional and international level | The ways/direction and content of the discussion and presentation of the exemption policy Key concepts: hierarchy, power, evidence, etc. | Participant observation in policy and maternal health meetings |
Sample summary: Benin: 1 conference and 10 agency meetings | ||||
2 | Interview guide with national and regional actors
Context and drivers; design and implementation
| Actors at the national, regional and international level | Introduction of the policy Perceptions of how the policy was put in place and how it works Actual implementation of the policy compared to official documents Elements of the political context necessary to ensure the policy is implemented and is effective Exchange between national, regional and international actors policy on the policy | Structured discussion with key informants |
Number of informants interviewed in the following countries: Benin: 24; Morocco:12; Burkina Faso:23; International: 9 | ||||
3 | Policy document review
Design and implementation
| National | Review of published reports, analyses, press releases and other documents related to the policy at national level | Thematic analysis |
4 | Financial flows tracking (FFT)
Financing of policies; facility finances
| National, regional, district, and health facility level | Budgets & expenditure Distribution per region and health services 3. Payment Schedule (and the kits/equipments where necessary) Consistency with the recorded activities Consistency and adequacy of funds arriving at the health facilities | A structured collection and analysis of secondary data |
Sites: Benin: national level; 6 regions; 5 districts; 7 hospitals Burkina Faso: national level; 5 regions; 6 districts; 12 hospitals (1 CHU, 2 CHR, 4 CMA, 6 CSPS) Morocco: national level; 6 districts; 8 hospitals (2 CHU, 2 CHR, 4 CHP) Mali: national level; 4 regions; 8 hospitals | ||||
5 | Costing
Financing of policies; facility finances
| Health facilities | Unit cost of production of key maternal health services: normal deliveries, complicated deliveries, caesarean sections, antenatal care, postnatal care | Based on interviews and a extraction of information from sample of medical records |
Sample: Benin: 7 hospitals in 5 districts; 1050 cases Burkina Faso: 6 districts; 6 hospitals (4 CMA, 2 CHR); 443 cases Morocco: No Costing tool Mali:4 CHR; 4 HD; 2 CSREF; 2691 cases | ||||
6 | Exit interviews (EI)
Household-level effects; quality of care
| Women who had a delivery, their husband or relatives who accompanied them at the hospital | Costs for a given delivery inside and outside hospitals Expenditure as a percentage of household consumption Healthcare seeking behaviour Access to health facilities Perceptions of quality of care | Structured questionnaire |
Benin: 663 women in total interviewed; 294 with a caesarean; 294 women with a complicated delivery; 81 women with normal delivery Burkina Faso:1609 women in total; 818 with a caesarean; 462 with complications; 316 with a normal delivery Morocco: 973 women in total; 423 with complications; 442 with caesareans; 108 with normal deliveries Mali: 589 women in total; 30 complicated deliveries; 345 caesareans; 188 normal deliveries; 26 without assistance/home delivery | ||||
7 | Health worker survey (HWIS)
Effects on human resources
| Health workers | Health workers and their workload Working hours Sources of income Motivation at the workplace Changes in the above factors, associated with the policy Perceptions of the policy | Structured questionnaire (with some open questions) |
Sample: Benin: 190 health workers; Burkina Faso: 130 health workers; Morocco: 187 health workers; Mali: 176 health workers | ||||
8 | The Policy implementation assessment (POLIAS)
Design and implementation
| District Hospitals | The start of the implementation of the policy The service package covered by the policy The proportion of facilities offering the service package free of charge and on a permanent basis The actual geographical coverage | Structured discussion with key informants; Documentary review (for triangulation purposes); Routine data extraction |
Benin: 5 districts and 7 hospitals; Burkina Faso: 6 districts and 6 hospitals; Mali: 8 districts and 8 hospitals; Morocco: 6 districts and 6 hospitals | ||||
9 | Policy Effects Mapping study (POEM)
Effects on health systems
| District Health management team Management team at the hospital Health workers | Governance Provision of care Human Resources Financial resources Drugs and equipment Health Information System Patients & the community | Interviews with key informants Documentary review Routine data extraction Check-list/observation |
Benin: 85 interviews in 4 districts hospital, 2 private hospital,1 departmental hospital, 10 health centres Burkina Faso: 57 interviews in 4 districts hospitals and 2 regional hospital and 12 health centres Mali: 84 interviews in 4 regional hospitals, 4 district hospital and 16 health centres. Morocco: 110 interviews in 5 districts hospital, 2 regional hospitals, 2 university hospital, 12 health centres | ||||
10 | Realist case studies
Factors behind differential implementation
| Districts hospitals | Actual implementation of the policy compared to official documents Perceptions of managers on the challenges posed by the new policy Mechanisms that explain the ownership and the implementation of policy at the operational level. Contextual elements necessary for the policy to be effective | Interviews with key informants Documentary review Routine data extraction Using data from other tools for triangulation. |
2 districts/country (excluding Mali); Benin: interviews from POEM; Burkina : interviews from POEM + 16 extra interviews to complete the analysis; Morocco: interviews from POEM | ||||
11 | Quantitative instrument on near-miss, caesarean sections and the quality of care
Impact on quality of care
| Women and newborns | The outcome of hospitalisation The demographic characteristics The reproductive history The causes of complications The near-miss definitions for women and newborns The indications for caesarean section Delays in receiving care Quality of care for caesarean section Quality of care for all women | Medical records and records of admitted women in the maternity ward (normal deliveries, near-miss, caesarean sections) |
Benin: 3361 deliveries; Burkina Faso: 1752 deliveries; Morocco: 3134 deliveries; Mali: 6386 deliveries | ||||
12 | Quantitative analysis of secondary data
Impact on utilisation; inequities of access
| National | Utilisation of facility delivery care Trends in caesarean section rates Equity of access | Segmented regression analysis of data from routine annual statistics and nationally-representative household survey data The model was specified as:
Y
t
= β
0
+ β
1
*time + β
2
*policy + β
3
*postslope + ε
t
Where Y
t
is the outcome variable (either facility delivery or caesarean delivery) at time t; time is a continuous variable; policy is a dummy variable indicating whether or not the policy has been implemented at time t; and postslope is coded 0 up to the last point before the introduction of the policy and coded sequentially from 1 thereafter Based on recommendations by [22] |
Benin: Demographic and Health Survey data for 1993–2011 (n = 36,375) Burkina Faso: routine data published by the Ministry of Health for 1992, 1998 2000–2010; Demographic and Health Survey data for 1988–2010 (n = 36,836) Mali: Demographic and Health Survey data for 1993–2013 (n = 43,952) Morocco: routine data published by the Ministry of Health for 1997–2011; Demographic and Health Survey data for 1987–1992, 1998–2011 (n = 16,679) | ||||
13 | Observation guide in health facilities
Impact on quality of care; other household-level effects
| Health facilities | Quality of care for all women Quality of care for caesarean sections Delays in receiving care Communication between staff, patients and their carers Resources (human, materials, etc.) Costs and payments for services | Participant observations in hospitals |
Benin : 4 weeks’ observation in 2 hospitals; Morocco :3 weeks’ observation in 2 sites | ||||
14 | Interview guide with women
Impact on quality of care; other household-level effects
| Health facilities/community (women) | Perceptions of quality of care Perceptions of costs related to hospital delivery Awareness of free care | Structured discussion with women after they return home |
Benin: 44 caesareans; 9 Near Miss; 9 “normal” deliveries; Morocco: 30 Near Miss |
Results
Context and drivers behind policies
Benin | Burkina Faso | Mali | Morocco | |
---|---|---|---|---|
Sources | DHS 2006 | DHS 2003 | DHS 2006 | DHS 2003–2004 |
Maternal Mortality ratio | 397/100,000 | 484/100,000 (DHS 1996) | 464/100,000 | 227/100,000 |
Neonatal Mortality rate | 32/1000 | 31/1000 | 46/1000 | 27/1000 |
% Skilled birth attendance rate | 78 % | 57 % | 49 % | 63 % |
Coverage of antenatal care (at least one visit) | 88 % | 73 % | 70 % | 68 % |
Coverage of antenatal care (at least four visits) | 61 % | 18 % | 35 % | 31 % |
% Caesarean deliveries | 4 % | 0.7 % | 1.6 % | 5.4 % |
“… I think word was getting out, around Africa, that this policy [charging user fees] was mad… To remove fees was good for the health sector and also brought big political benefits. And I would say this whole thing has been a politically driven process rather than a technical one, and that remains to this day. […] I think a lot of developing country governments now are rather sceptical about the advice they’re getting from development agencies, because in many respects, we forced them into this in the first place, so for us to now turn around and say ‘oh no, you shouldn’t do that, you should remove them’ – I think that people are sceptical about a lot of the advice that we are providing.” – Consultant with international agencies, global level (GL1)
Design and Implementation of the policies
Financing
Health systems effects
Human resources
Country | Professional category | No. of hours worked (incl. on call) | No. of patients seen | No. of deliveries performed |
---|---|---|---|---|
Burkina Faso | Doctors | 42 | 45 | 3 |
Midwives | 44 | 44 | 6 | |
Nurses | 46 | 71 | 6 | |
Morocco | Doctors | 70 | 36 | 0 |
Midwives | 48 | 74 | 25 | |
Nurses | 40 | 20 | 8 | |
Benin | Doctors | 48 | 28 | 6 |
Midwives | 48 | 26 | 12 | |
Nurses | 48 | 16 | 4 | |
Mali | Doctors | 40 | 33 | 4 |
Midwives | 40 | 25 | 6 | |
Nurses | 36 | 27 | 3 |
Facility finances
IT systems
Drugs and supplies
Management
Factors behind differential implementation
Impact on utilisation
Impact on other (untargeted) services
Impact on quality of care
Other household-level effects and influencers
Delay in seeking care and health seeking behaviour
Inequities of access
Financial impact for households
HH Expenditure per month | Excess amount paid per CS | Total payment for CS | Excess as % of total payment | Payment per CS as % of median household expenditure | |
---|---|---|---|---|---|
Burkina Faso | 61.89 | 6.25 | 36 | 17 | 58 |
Morocco | 178.26 | 1.44 | 63.2 | 2 | 35 |
Benin | 90.89 | 8.74 | 64.54 | 14 | 71 |
Mali | 100.90 | 23.92 | 49.2 | 49 | 49 |
HH Expenditure per month (EUR) | Excess amount paid per ND (EUR) | Total payment for ND (EUR) | Excess as % of total payment | Payment per normal delivery as % median HH expenditure | |
---|---|---|---|---|---|
Burkina Faso | 61.89 | 0.61 | 16.23 | 4 | 26 |
Morocco | 178.26 | 3.12 | 48.73 | 6 | 27 |
Quintile 1 | Quintile 2 | Quintile 3 | Quintile 4 | Quintile 5 | Average payment (Euros) | ||||||
---|---|---|---|---|---|---|---|---|---|---|---|
Urban | Rural | Urban | Rural | Urban | Rural | Urban | Rural | Urban | Rural | ||
Burkina Faso | 56 | 71 | 115 | 78 | 35 | 124 | 40 | 60 | 23 | 60 | 50 |
Morocco | 52 | 54 | 44 | 58 | 35 | 32 | 31 | 36 | 23 | 69 | 49 |
Mali | 147 | 64 | 49 | 50 | 89 | 62 | 32 | 37 | 34 | 52 | 50 |
Benin | 139 | 170 | - | 124 | 124 | 163 | 106 | 170 | 133 | 101 | 83 |
Discussion and conclusions
-
The policies have been relatively thoroughly implemented: despite some gaps and lapses, the policies have been put into effect in a serious way
-
They have not been affected by budget shortfalls, which undermined the effectiveness of similar policies in countries like Ghana [21]
-
They have, in some cases, like Morocco’s, been accompanied by the additional supply-side improvements which are required to meet the additional demands
-
There is an underlying support for them, and not only from beneficiaries: most actors within the health system (health district managers, hospital management teams, specialists, nurses and midwives) reacted positively to the policy in interviews. The policy was generally considered to be relevant and important
-
They have achieved substantial reductions in household payments, which will over time contribute to poverty reduction and reduced inequalities of access
-
A package of care which in some cases (Mali and to a lesser extent Benin given its utilisation rates) will not address all of the main causes of maternal and early neonatal morbidity and mortality, and whose impact on these can therefore only be expected to be modest, even if well implemented
-
Poorly calibrated provider payments for those using fixed payments, which either over-incentivise (in the case of Benin) or under-fund (in the case of Mali). Both of these result in perverse effects and stem in part from poorly understood cost structures
-
Lack of clear and well disseminated operating documents, which enable staff and clients to be clear about how the policy will work and what is covered by it
-
Too limited attention to the quality of care offered by the facilities covered by the policy; for newborns in particular it has been found to be sub-standard
-
Lack of involvement in most cases of managers, staff and communities in developing and monitoring the policy in order to increase ownership and control abuse
-
No policy has completely reduced the officially exempted costs to zero; although magnitudes of unwarranted payments vary in scale, all countries need to more effectively regulate providers and stop illicit payments from patients
-
By their very design, the policies are unable to address some of the main barriers faced by women, such as the inability to physically access health care. Additional actions are needed to ensure that benefits can be equitable