ReviewEffective financing of maternal health services: A review of the literature☆
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.
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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.