Free maternal health policy. Is it really working?
Developing countries, such as Ghana, continue to bear a large portion of pregnancy-related deaths.
It is recognised that access to skilled delivery care of good quality will contribute to reducing maternal and prenatal mortality and morbidity.
The importance of this situation is reflected in the Millennium Development Goal (MDG) 5 aimed at reducing maternal mortality ratios by 75% by the year 2015 and to increase the number of skilled attendants at delivery by two-thirds.
In Ghana, maternal mortality ratio is estimated at 450 per 100,000 live births and skilled attendants have actually fallen from 45% t0 34 %.
Among the key reasons are delays in accessing care due to lack of financing, delays in obtaining and paying for transport and delays at the health facility due to poor quality of care and cost of service.
To address these, the Ministry of Health of Ghana in September 2003 introduced an exemption policy directed at making delivery care free. The cost was paid from HIPC funds and channeled through the district assemblies and later through the health facilities directly.
The exemptions were financed through the National Health Insurance Scheme (NHIS) initially with funds from the British Department for International Development (DfID) and now it is from the National Health Insurance Fund (NHIF).
The thrust of these policies have been to improve uptake, quality and financial and geographic access to delivery care services.
The services covered by the exemption policy are normal deliveries, assisted deliveries, including Caesarean section, and management of medical and surgical complications arising out of deliveries, including the repair of vesico-vaginal and recto-vaginal fistula.
However, the implementation of this policy has met with some challenges because persons charged with ensuring that the exemption is applied are not at post or show no interest in its implementation.
As a result some mothers are still, sadly, detained at some health facilities.
For example, the Korle bu Teaching Hospital in Accra, runs a 24-hour service.
However, because persons in charge of payment at the Hospital, especially the Maternity Block, are to not available all the time, mothers or patients who are discharged find it difficult to pay their bills for them to go home.
Some frustrated mothers who spoke to the GNA expressed grave concern at the situation saying that the free maternal health policy was not working after all.
They also contend that despite the policy they still pay for some services rendered.
Ms Veronica Mensah, who had just given birth at the Hospital, told the GNA that she spent an extra day after she was discharged because the cashier who had to be at post for her to pay her bill to be released was not present.
This, she angrily says, made her to remain unnecessarily in hospital for another day.
“I thought that it was to curtail these occurrences that the free maternal health policy was introduced but I beg to differ this is not really so. This indiscipline must stop and people should be held accountable for their responsibility,” Ms Mensah said.
Another client of the Hospital who gave her name as Akweley from Chorkor in Accra said: “I was detained when I had my second child because I could not afford to pay for Cesarean session and was released from hospital because a Good Samaritan paid my bills.”
Other women who spoke to GNA confirmed the practice and indiscipline on the part of some hospital staff.
While some said they paid almost nothing after delivery others said they were made to pay some bills after delivery.
Ms Bernice Danquah told the GNA that in 2010 when she went to deliver she was registered with the NHIS. However, she was made to pay GHC45.50 for Patient Discharge Form Service, GHC3.70 for drugs and GHC12.00 for what was not indicated on a Ministry of Health receipt.
She said the bill she had to pay was not her problem. Her worry was that she was detained for another day because the cashier at the Maternity Block was not at post to receive her payment.
However, when contacted for their reaction, the management of the Korle-bu Teaching Hospital expressed surprise at the turn of events.
The Head of Hospital Public Relations Unit, Mr Mustapha Salifu, said the Hospital together with the Ministry of Finance and Economic Planning in 2009 introduced payment platforms to facilitate payment for services and products. He was therefore surprised that payment continued to be a problem.
According to him the payment points were available at the Central Out Patient Department, Children, Gynaecology, Surgical, Pathology and Ear, Nose and Throat Departments.
Mr. Salifu contended that under the free maternal health policy, no woman was expected to pay for delivery and found it rather strange that complaints were coming from the Maternity Unit.
He said payments could only be made in complicated cases which were unrelated to deliveries and that even with that the payment points were available.
Mr Salifu further explained that expectant mothers, including those who had been referred and emergencies that were not covered by NHIS, were taken on board at the point of delivery and were not expected to be paid for.
He said the Hospital would look into the complaints and remedy the situation should the allegations turn out to be true.
In an interview with the GNA, Dr Sam Adjei, former Deputy Director-General of the Ghana Health Service (GHS) and currently the Chief Executive of the Centre for Health and Social Services (CHeSS), who co-authored a research on Free Maternal Health Policy in Ghana, said an evaluation of the exemption policy over the period 2005-2006 showed that it positively affected uptake of delivery by skilled attendants at delivery and also benefitted poor pregnant women who lacked the financial resources to pay for delivery at a health facility.
He, however, said for continual effectiveness there was the need to have a systematic monitoring and evaluation system in place, and reward and sanctions for those working on the policy at the operational levels. Midwives also need frequent supervision and quality improvement training.
There is a growing movement, globally and particularly in the Africa region, to reduce financial barriers to health care generally, and with special emphasis on high priority services and vulnerable groups.
In Burundi, for example, free services for pregnant women and the under-five were introduced in 2006, and utilization appears to have increased as a result, though no formal evaluation has been undertaken
In Zambia, fees were suspended for rural districts in 2006 while in Burkina Faso an 80% subsidy policy for deliveries was launched in 2006. Other countries have followed suit, though with varying target groups.
The Kenyan example indicates various changes have been made to the user fee regime. Most recently, in 2007, deliveries were announced to be free, though there is no evidence yet of implementation or impact.
Liberia suspended fees for primary care in 2007 while Niger announced free care for children late in 2007. Sudan also announced free care for Caesarean sections and children in January 2008.
The movement towards making delivery care free to all women is a bold and timely action which is supported by evidence from within and beyond Ghana.
However, the potential for this to translate into reduced mortality for mothers and babies fundamentally depends on the effectiveness of its implementation. GNA