Elsevier

Health Policy

Volume 75, Issue 1, December 2005, Pages 49-58
Health Policy

Review
Effective financing of maternal health services: A review of the literature

https://doi.org/10.1016/j.healthpol.2005.02.002Get rights and content

Abstract

Health care can be funded in a number of ways ranging from direct user charges (out of pocket) payments to indirect methods that pool across time (prepayment) and across different risk and wealth groups (insurance and general taxation). All these methods can be used to finance maternal health services. When assessing the impact of financing mechanisms it is important to be aware of the different ways they effect service delivery patterns and utilisation. Specifically most systems have both equity and efficiency aspects that combine to impact on health service utilisation and health status.

In general indirect methods that help families to pool the costs of maternal health services are preferable to direct methods of payment. It is also clear, however, that user charges may sometimes help to mitigate deficiencies in systems of pooled funding. Available literature suggests that financing mechanisms for maternal health services could be improved by systems that increase transparency, help to mitigate demand-side costs of services and provide funding for that promote transparent charging for services. While the limited experience of demand-side mechanisms for improving access to maternal health services more evaluation is required.

Introduction

Equitable financing mechanisms that generate sufficient revenue and encourage efficient provision of services are essential for the delivery of high quality and responsive maternal health services. There are two principal ways of paying for health services. Direct payments or user charges are made out of pocket usually at time of service. Indirect or insurance mechanisms are based on pooling mechanisms where target groups pay a regular contribution and from which the expenses of treatment are financed when a member of the group falls sick. Within this latter category fall universal systems of public health care financed by general taxation, social insurance which pay for the costs of a defined employment or geographic group based on payroll or other contributions and voluntary insurance including community based insurance aimed at the informal and rural sector.

Three features of maternal health care mean that, in general, insurance, or at least pre-payment, is preferred to direct user payments. Firstly, medical services for women during pregnancy are usually essential with potentially life-threatening implications if not obtained. Secondly, maternal care can often be expensive, absorbing a substantial fraction of a household's disposable income at a time when income-generating capability is low. Finally, while basic delivery care is required for all women, care during complications is uncertain making it difficult for households to plan for the financial consequences. Relying on direct payment alone can mean that paying for health services can have catastrophic implications for the household economy. These are the key features that led WHO to make fairness of financing contributions based on increased pooling one of the three pillars of a successful health system [1].

This review is divided into three main sections. The first two sections review the existing evidence of financing on equity and incentives, respectively. Financing mechanisms have a number of potential effects on consumers and providers that need to be disentangled. The two main ones are on an individual's ability to finance the costs of service (equity and cost sharing) and the incentives on both provider and consumer behaviour. The final section discuss some of the main implications for maternal health and ways in which financing mechanisms might be extended in the future to make them more responsive to the needs of safe motherhood. The review is based on a structured search of the literature on financing relating to reproductive and maternal health1.

Section snippets

Direct financing mechanisms

Definitions of equity vary and are dependent on the values of society. A common definition is that health services should benefit in proportion to need while being financed progressively or proportionately2. User charges tend to be regressive, since they place a

Incentives

All financing systems introduce incentives which affect both consumer and provider behaviour. On the consumer side the key concern is that up front payments are required when a patient is ill which tend to encourage delays in treatment. Evidence for this is available in both very rich (US) and very poor (Vietnam) countries [42], [43]. Insurance and pre-payment methods should help to reduce the delay and increase timeliness of treatment although specific rules about what is covered may hinder

Improving financing of maternal care

In this section we attempt to draw some lessons from diverse but often fragmented health-financing experience as it relates to maternal health.

References (62)

  • WHO. The World Health Report 2000. Health systems: improving performance, Geneva, World Health Organisation...
  • de Feranti D. Paying for Health Services in Developing Countries. World Bank Staff Working Papers 721. Washington:...
  • Akin J. Financing Health Services in Developing Countries: An Agenda for Reform, World Bank...
  • K. Harrison

    Maternal mortality in Nigeria: the real issues

    African Journal of Reproductive Health

    (1997)
  • Kwast B, Vickery C. A review of safe motherhood in Tanzania. London, Options Consultancy Services Limited for DFID. UK...
  • M. Kowalewski et al.

    Can Mothers afford maternal health care costs? User costs of maternity services in rural Tanzania

    African Journal of Reproductive Health

    (2002)
  • Quisumbing AR, Maluccio JA. Intrahousehold allocation and gender relations: new empirical evidence. Policy research...
  • Gertler P, van der Gaag J. Modeling the Demand for Health Care. The Willingness to Pay for Medical Care. Washington,...
  • B.E. Booth et al.

    Decreased access to medical-care for girls in Punjab, India – the roles of age, religion, and distance

    American Journal of Public Health

    (1992)
  • Begum S, Sen B. Not quite, not enough: financial allocation and the distribution of resources in the health sector....
  • Borghi J, Ensor T, Neupane BD, Tiwari S. Coping with the Burden of the Costs of Maternal Health. Kathmandu, Nepal Safer...
  • Bennett S, Creese A, Monasch R. Health insurance schemes for people outside formal sector employment. Analysis,...
  • D. Wilkinson et al.

    Effect of removing user fees on attendance for curative and preventive primary health care services in rural South Africa

    Bulletin of the World Health Organisation

    (2001)
  • Deininger K, Mpuga P. Economic and welfare effects of the abolition of health user fees: evidence from Uganda. Policy...
  • Garshong B, Dakpallah G, Huijts I, Adjei S. ‘We are still paying’ A Study on factors affecting the implementation of...
  • Bitran R, Giedion U. Waivers and exemptions for health services in developing countries. Social Protection Discussion...
  • Institute of Policy Studies. Equity in financing and delivery of health services in Bangladesh, Nepal and Sri Lanka:...
  • J. Killingsworth et al.

    Unofficial fees in Bangladesh: price, equity and institutional issues’

    Health Policy and Planning

    (1999)
  • Mcpake BDA, Mwesigye F, Ofumbi M, Ortenblad L, Streefland P, Turinde A. “Informal economic activities of public health...
  • S. Nahar et al.

    The hidden cost of ‘free’ maternity care in Dhaka, Bangladesh

    Health Policy and Planning

    (1998)
  • Blanchett T. Women's Reproductive Health: problems and issues in Greater Sylhet. Anthropological input to Inform...
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    This work was undertaken as part of an international research programme – Initiative for Maternal Mortality Programme Assessment (IMMPACT), (see: http://www.abdn.ac.uk/immpact/), funded by the Bill and Melinda Gates Foundation, the Department for International Development, the European Commission and USAID. The funders have no responsibility for the information provided or views expressed in this paper. The views expressed herein are solely those of the authors.

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