Community health insurance

Conclusion This paper demonstrates that the distribution of benefits among members of this community-financing scheme is equitable, and that such a degree of equity in community insurance can be achieved in such settings, possibly through an emphasis on accountability and local management. Such a scheme presents a workable model for investing in primary health care in resource-poor settings.

Le Rwanda a connu de nombreuses difficultés au cours des deux dernières décennies : la situation économique précaire, les guerres civiles, le régime politique défaillant, l'instabilité de la sous-région des Grands Lacs, la pandémie du VIH/SIDA ; tous ces bouleversements ont ...

Introduction In sub-Saharan Africa, there is limited evidence on the COVID-19 health-related effect from front-line health provision settings. Therefore, this study aimed to analyse the effect of the COVID-19 pandemic on routine maternal and neonatal health services in three referral hospitals. Materials and methods We conducted an observational study using aggregate monthly maternal and neonatal health services routine data for two years (March 2019–February 2021) in three referral hospitals including two maternities: Hôpital National Ignace Deen (HNID) in Conakry and Hôpital Regional de Mamou (HRM) in Mamou and one neonatology ward: Institut de Nutrition et de Santé de l’Enfant (INSE) in Conakry. We compared indicators of health service utilisation, provision and health outcomes before and during the COVID-19 pandemic periods. An interrupted time-series analysis (ITSA) was performed to assess the relationship between changes in maternal and neonatal health indicators and COVID-19 ...

Objective  To describe the implementation of facility‐based case reviews (medical audits) in a maternity unit and their effect on the staff involved.Design  Cross‐sectional descriptive study.Setting  A 26‐bed obstetric unit in a district hospital in Ouagadougou, Burkina Faso.Sample  Sixteen audit sessions conducted between February 2004 and June 2005. Thirty‐five staff members were interviewed.Methods  An analysis of all the tools used in the management of the audit was performed: attendance lists, case summary cards and register of recommendations. The perceptions of the staff about the audits were collected through a questionnaire administrated by an external investigator from 10 June 2005 to 16 June 2005.Main outcome measures  Session participation, types of problems identified, recommendations proposed and implemented and staff reaction to the audits.Results  Only 7 midwives from a total of 15 regularly attended the sessions. Eighty‐two percent of the recommendations made during...

Introduction: Access to basic healthcare services for the whole population has been a priority the successive governments in Senegal since independence. Mutual health insurance has been the driving force behind health coverage since the 2000s. This policy aimed to reach 75% coverage of the population by 2019. This study aims to describe the characteristics and also analyze the viability of mutual health insurances in Vélingara. Methodology: The mixed method was used to evaluate both the viability of mutual health insurances and the perception of the communities. Viability was evaluated in its four technical, functional, financial and institutional aspects. For the population's perception, interviews were conducted with beneficiaries, nonbeneficiaries, community leaders and UHC officials. Results: At the institutional level, all of the mutual health insurances were viable and had internal regulations, a statute, a license and a bank account. On the technical level, they were exposed to the risk of adverse selection. On the other hand, from a functional point of view, none of mutual health insurances was viable, with a very low rate of retention. Finally, from a financial point of view, none of the mutual health insurances had the capacity to honor their medium-and long-term debts without resorting to external resources. In addition, the results of the survey showed a lack of information and a high cost of membership. Conclusion: All the mutual health insurances were experiencing difficulties and required urgent corrective measures and support from the state and local authorities.

In January 2005, a cost-sharing system was introduced into Secteur 30 health district, an urban district of the city of Ouagadougou, with the aim of improving access to emergency obstetric care for pregnant women in the district. The cost-sharing covers emergency transport and caesarean deliveries. The direct costs are shared between four parties: 1) the management committees of health centres and confessional health facilities, 2) the woman and her family, 3) the local authorities and 4) the health district. These different contributions reduce the family's share and generate a surplus for treating the poorest inhabitants of the district. Three years after implementation, the results have been measured in terms of service utilisation, quality of care, financial viability and perception of the system by the different parties involved. Data were collected from several sources: routine data from the health information system, individual prescription forms, an Unmet Obstetrical Needs (UON) study and individual interviews with the different parties. The coverage of assisted deliveries in the district rose from 66.

Although quality health facilities in Mumbai and Pune are plenty, slum dwellers do not benefit fully from these. Next to financial barriers, low quality treatment and discrimination form major hurdles to entering public care. A lot of them prefer to buy services from ill-qualified private providers. Without social protection in health (SPH), their predicament often boils down to the uneasy choice between forgoing treatment and risking impoverishment. Currently, some SPH interventions try to protect poor urbanites and increase their access to quality care. This article provides more insight into the health service encounter experienced by female slum dwellers. Using data from focus group discussions with members of three SPH interventions and in-depth interviews with providers, challenges faced by the women during their health seeking process are discussed. By using Bourdieu's theoretical concepts on field, capitals and habitus, this study shows that a more subtle reproduction of social inequities and domination in the medical field forces slum dwellers to either forgo treatment, buy ineffective care from private providers, or passively accept the abuse in the public sector. These insights demonstrate the need for transformative SPH interventions to address the power imbalances in society that create and sustain the social vulnerability of poor people when seeking health.

Introduction: Access to basic healthcare services for the whole population has been a priority the successive governments in Senegal since independence. Mutual health insurance has been the driving force behind health coverage since the 2000s. This policy aimed to reach 75% coverage of the population by 2019. This study aims to describe the characteristics and also analyze the viability of mutual health insurances in Vélingara. Methodology: The mixed method was used to evaluate both the viability of mutual health insurances and the perception of the communities. Viability was evaluated in its four technical, functional, financial and institutional aspects. For the population's perception, interviews were conducted with beneficiaries, nonbeneficiaries, community leaders and UHC officials. Results: At the institutional level, all of the mutual health insurances were viable and had internal regulations, a statute, a license and a bank account. On the technical level, they were exposed to the risk of adverse selection. On the other hand, from a functional point of view, none of mutual health insurances was viable, with a very low rate of retention. Finally, from a financial point of view, none of the mutual health insurances had the capacity to honor their medium-and long-term debts without resorting to external resources. In addition, the results of the survey showed a lack of information and a high cost of membership. Conclusion: All the mutual health insurances were experiencing difficulties and required urgent corrective measures and support from the state and local authorities.

objective To describe the implementation of a cost-sharing system for emergency obstetric care in an urban health district of Ouagadougou, Burkina Faso and analyse its results after 1 year of activity. methods Service availability and use, service quality, knowledge of the cost-sharing system in the community and financial viability of the system were measured before and after the system was implemented. Different sources of data were used: community survey, anthropological study, routine data from hospital files and registers and specific data collected on major obstetric interventions (MOI) in all the hospitals utilized by the district population. Direct costs of MOI were collected for each patient through an individual form and monitored during the year 2005. Rates of MOI for absolute maternal indications (AMI) were calculated for the period 2003-2005. results The direct cost of a MOI was on average 136US$, including referral cost. Through the costsharing system this amount was shared between families (46US$), health centres (15US$), Ministry of Health (38US$) and local authority (37US$). The scheme was started in January 2005. The rate of cost recovery was 91.3% and the balance at the end of 2005 was slightly positive (4.7% of the total contribution). The number of emergency referrals by health centres increased from 84 in 2004 to 683 in 2005. MOI per 100 expected births increased from 1.95% in 2003 to 3.56% in 2005 and MOI for AMI increased from 0.75% to 1.42%. conclusions The dramatic increase in MOI suggests that the cost-sharing scheme decreased financial and geographical barriers to emergency obstetric care. Other positive effects on quality of care were documented but the sustainability of such a system remains uncertain in the dynamic context of Burkina Faso (decentralization). keywords emergency obstetric care, access to health care, financing, equity, urban health, Burkina Faso

We are most grateful to the authors of the papers of this book. Without their commitment to extensively review the literature on the specific topics and to draw upon their personal experiences, this volume would not have seen the light. The researchers presented their findings during the November 2000 EC meeting in Brussels offering the basis for the lively discussions and for the EC strategy paper. We were happy to welcome participants from developing countries who accepted, despite the short notice, to contribute by giving a critical review of every topic:

To improve access to maternal health services, Benin introduced in 2009 a user fee exemption policy for caesarean sections. Similar to other low-and middle-income countries, its implementation showed mixed results. Our study aimed at understanding why and in which circumstances the implementation of this policy in hospitals succeeded or failed. We adopted the realist evaluation approach and tested the initial programme theory through a multiple embedded case study design. We selected two hospitals with contrastive outcomes. We used data from 52 semi-structured interviews, a patient exit survey, a costing study of caesarean section and an analysis of financial flows. In the analysis, we used the intervention-context-actor-mechanism-outcome configuration heuristic. We identified two main causal pathways. First, in the state-owned hospital, which has a publicoriented but administrative management system, and where citizens demand accountability through various channels, the implementation process was effective. In the non-state-owned hospital, managers were guided by organizational financial interests more than by the inherent social value of the policy, there was a perceived lack of enforcement and the implementation was poor. We found that trust, perceived coercion, adherence to policy goals, perceived financial incentives and fairness in their allocation drive compliance, persuasion, positive responses to incentives and self-efficacy at the operational level to generate the policy implementation outcomes. Compliance with the policy depended on enforcement by hierarchical authority and bottom-up pressure. Persuasion depended on the alignment of the policy with personal and organizational values. Incentives may determine the adoption if they influence the local stakeholder's revenue are trustworthy and perceived as fairly allocated. Failure to anticipate the differential responses of implementers will prevent the proper implementation of user fee exemption policies and similar universal health coverage reforms.

Background: The aim of this paper was to evaluate the effectiveness and cost-effectiveness of alternative training strategies for increasing access to emergency obstetric care in Burkina Faso. Methods: Case extraction forms were used to record data on 2305 caesarean sections performed in 2004 and 2005 in hospitals in six out of the 13 health regions of Burkina Faso. Main effectiveness outcomes were mothers' and newborns' case fatality rates. The costs of performing caesarean sections were estimated from a health system perspective and Incremental Cost-Effectiveness Ratios were computed using the newborn case fatality rates. Results: Overall, case mixes per provider were comparable. Newborn case fatality rates (per thousand) varied significantly among obstetricians, general practitioners and clinical officers, at 99, 125 and 198, respectively. The estimated average cost per averted newborn death (x 1000 live births) for an obstetrician-led team compared to a general practitioner-led team was 11 757 international dollars, and for a general practitioner-led team compared to a clinical officer-led team it was 200 international dollars. Training of general practitioners appears therefore to be both effective and cost-effective in the short run. Clinical officers are associated with a high newborn case fatality rate. Conclusion: Training substitutes is a viable option to increase access to life-saving operations in district hospitals. The high newborn case fatality rate among clinical officers could be addressed by a refresher course and closer supervision. These findings may assist in addressing supply shortages of skilled health personnel in sub-Saharan Africa.

Caesarean deliveries are not funded by medical schemes unless clinically motivated by the provider. Although they are not covered by schemes, caesarean sections rates in the private sector are reported to be amongst the highest in the world, these procedures are also ...

In Mauritania, obstetrical risk insurance (ORI) has been progressively implemented at the health district level since 2002 and was available in 25% of public healthcare facilities in 2015. The ORI scheme is based on pre-payment scheme principles and focuses on increasing the quality of and access to both maternal and perinatal healthcare. Compared with many community-based health insurance schemes, the ORI scheme is original because it is not based on risk pooling. For a pre-payment of 16-18 USD, women are covered during their pregnancy for antenatal care, skilled delivery, emergency obstetrical care [including caesarean section (C-section) and transfer] and a postnatal visit. The objective of this study is to evaluate the impact of ORI enrolment on maternal and child health services using data from the Multiple Indicator Cluster Survey (MICS) conducted in 2015. A total of 4172 women who delivered within the last 2 years before the interview were analysed. The effect of ORI enrolment on the outcomes was estimated using a propensity score matching estimation method. Fifty-eight per cent of the studied women were aware of ORI, and among these women, more than two-thirds were enrolled. ORI had a beneficial effect among the enrolled women by increasing the probability of having at least one prenatal visit by 13%, the probability of having four or more visits by 11% and the probability of giving birth at a healthcare facility by 15%. However, we found no effect on postnatal care (PNC), C-section rates or neonatal mortality. This study provides evidence that a voluntary pre-payment scheme focusing on pregnant women improves healthcare services utilization during pregnancy and delivery. However, no effect was found on PNC or neonatal mortality. Some efforts should be exerted to improve communication and accessibility to ORI.

To examine trends in the utilisation of facility-based delivery care and caesareans in Morocco between 1987 and 2012, particularly among the poor; and to assess whether uptake increased at the time of introduction of policies or programmes aimed at improving access to intrapartum care. Using data from nationally-representative household surveys and routine statistics, our analysis focused on whether women delivered within a facility, and whether the delivery was by caesarean; analyses were stratified by relative wealth quintile and public/private sector where possible. A segmented Poisson regression model was used to assess whether trends changed at key events. Uptake of facility-based deliveries and caesareans in Morocco has risen considerably over the past two decades; particularly among the poor. The rate of increase in facility deliveries was much faster in the poorest quintile (annual increase RR: 1.09; 95% CI: 1.07-1.11) than the richest quintile (annual increase RR: 1.01; 95%...

Interest in community health insurance has grown rapidly in many developing countries, usually as a result of the weak capacity of governments to raise sufficient tax revenues and then to secure an adequate share for health care. There are many pitfalls, however, and only under specific conditions do community health insurance schemes appear to succeed in effectively improving access to care and enhancing financial protection against health care costs. In this paper, we focus on the initial experience with community health insurance in 19th century Japan, called 'Jyorei'. Whereas Jyorei began in 1835 in one village in Fukuoka Prefecture, it gradually expanded and the basic ideas came under government stewardship. It was scaled up as the core model of the National Citizen's Health Insurance Fund, one of the pillars of the Japanese social health insurance system. Several Jyorei success points are relevant today for developing countries wishing to support community health insurance. One of the key characteristics was social cohesion and the acceptance of equity goals with transfers between the rich and the poor.

The CENTER FOR DEVELOPMENT RESEARCH (ZEF) was established in 1995 as an international, interdisciplinary research institute at the University of Bonn. Research and teaching at ZEF aims to contribute to resolving political, economic and ecological development problems. ZEF closely cooperates with national and international partners in research and development organizations. For information, see: http://www.zef.de. ZEF-DISCUSSION PAPERS ON DEVELOPMENT POLICY are intended to stimulate discussion among researchers, practitioners and policy makers on current and emerging development issues. Each paper has been exposed to an internal discussion within the Center for Development Research (ZEF) and an external review. The papers mostly reflect work in progress.

IntroductionLa mortalite maternelle reste encore elevee dans les pays en developpement notamment en Afrique ou une femme parmi 16 en âge de reproduction sera touchee par cette mortalite contre 1 femme parmi 2400 dans les pays developpes. Au Burkina Faso, ce risque de mortalite est de 1 parmi 12 pour une femme en âge de reproduction.La litterature internationale montre qu’un meilleur acces aux soins qualifies a l’accouchement et aux soins obstetricaux d’urgence est la solution majeure pour sauver la vie d’une femme au cours de la grossesse, de l’accouchement et dans le post partum. Elle montre que cet acces est limite en milieu rural par l’existence de barrieres liees aux services de sante, de barrieres economiques et sociales. Au milieu des annees 1990, il a ete montre qu’il serait possible d’ameliorer l’acces des femmes aux soins qualifies et aux soins d’urgence par des interventions locales visant a reduire ces barrieres. Ces resultats ont entraine la mise en place de plusieurs in...

One of the constraints in the utilisation of maternal healthcare in India is the out-of-pocket expenditure. To improve the utilisation and to reduce the out-of-pocket expenditure, India launched a cash incentive scheme, Janani Suraksha Yojana (JSY), which provides monetary incentive to the mothers delivering in public facility. However, no study has yet examined the extent to which the JSY payments reduce the maternal healthcare induced catastrophic out-of-pocket expenditure burden of the households. This paper therefore attempts to examine the extent to which the JSY reduces the catastrophic expenditure estimate household expenditure on maternity, , all direct and indirect expenditure. The study used data on 396 mothers collected through a primary survey conducted in the rural areas of the Varanasi district of Uttar Pradesh state in 2013-2014. The degree and variation in the catastrophic impact of households' maternity spending was computed as share of out-of-pocket payment in ...

Background: Use of maternal health care in low-income countries has been associated with several socioeconomic and demographic factors, although contextual analyses of the latter have been few. A previous study showed that 75% of women with severe obstetric morbidity (nearmiss) identified at hospitals in La Paz, Bolivia were in critical conditions upon arrival, underscoring the significance of pre-hospital barriers also in this setting with free and accessible maternal health care. The present study explores how health care-seeking behaviour for near-miss morbidity is conditioned in La Paz, Bolivia. Methods: Thematic interviews with 30 women with a near-miss event upon arrival at hospital. Near-miss was defined based on clinical and management criteria. Modified analytic induction was applied in the analysis that was further influenced by theoretical views that care-seeking behaviour is formed by predisposing characteristics, enabling factors, and perceived need, as well as by socially shaped habitual behaviours. Results: The self-perception of being fundamentally separated from "others", meaning those who utilise health care, was typical for women who customarily delivered at home and who delayed seeking medical assistance for obstetric emergencies. Other explanations given by these women were distrust of authority, mistreatment by staff, such as not being kept informed about their condition or the course of their treatment, all of which reinforced their dissociation from the health-care system. Conclusion: The findings illustrate health care-seeking behaviour as a practise that is substantially conditioned by social differentiation. Social marginalization and the role health institutions play in shaping care-seeking behaviour have been de-emphasised by focusing solely on endogenous cultural factors in Bolivia.

One of the constraints in the utilisation of maternal healthcare in India is the out-of-pocket expenditure. To improve the utilisation and to reduce the out-of-pocket expenditure, India launched a cash incentive scheme, Janani Suraksha Yojana (JSY), which provides monetary incentive to the mothers delivering in public facility. However, no study has yet examined the extent to which the JSY payments reduce the maternal healthcare induced catastrophic out-of-pocket expenditure burden of the households. This paper therefore attempts to examine the extent to which the JSY reduces the catastrophic expenditure estimate household expenditure on maternity, , all direct and indirect expenditure. The study used data on 396 mothers collected through a primary survey conducted in the rural areas of the Varanasi district of Uttar Pradesh state in 2013-2014. The degree and variation in the catastrophic impact of households' maternity spending was computed as share of out-of-pocket payment in ...

One of the constraints in the utilisation of maternal healthcare in India is the out-of-pocket expenditure. To improve the utilisation and to reduce the out-of-pocket expenditure, India launched a cash incentive scheme, Janani Suraksha Yojana (JSY), which provides monetary incentive to the mothers delivering in public facility. However, no study has yet examined the extent to which the JSY payments reduce the maternal healthcare induced catastrophic out-of-pocket expenditure burden of the households. This paper therefore attempts to examine the extent to which the JSY reduces the catastrophic expenditure estimate household expenditure on maternity, , all direct and indirect expenditure. The study used data on 396 mothers collected through a primary survey conducted in the rural areas of the Varanasi district of Uttar Pradesh state in 2013-2014. The degree and variation in the catastrophic impact of households' maternity spending was computed as share of out-of-pocket payment in ...

Background The World Health Organization Safe Childbirth Checklist tool was specifically designed for developing countries such as sub-Saharan African countries, to ensure safety and security of the couple mother and newborn around the time of childbirth. However, the implementation of the Safe Childbirth Checklist tool requires a good knowledge of the context setting to face challenges. Our study objectives were (1) to assess the acceptability of the WHO SCC tool and (2) to identify conditions and strategies for a better introduction and use of the WHO SSC tool. Methods This was a pilot multi-country study conducted from January to March 2019 in Burkina Faso and Côte d’Ivoire, respectively, in the health regions of central-North and Agnéby-Tiassa-Mé. In each health region, 5 health facilities of different levels within the health system pyramid were selected through a purposive sampling. The study was conducted in 2 phases: 38 healthcare providers and 15 managers were first trained...

We do not work with preconceived ideas for solutions, westernbased blueprints or donor-specific protocols. We organize exchange between local and international partners to link local effectiveness to international knowledge. Results and conclusions Application of new insights in implementation theory and complexity management leads to a dynamic process of change, rather than traditional project implementation.

Background: We describe a step-wedge cluster-randomised community-based trial which has been conducted since 2003 to accompany the implementation of a community health insurance (CHI) scheme in West Africa. The trial aims at overcoming the paucity of evidence-based information on the impact of CHI. Impact is defined in terms of changes in health service utilisation and household protection against the cost of illness. Our exclusive focus on the description and discussion of the methods is justified by the fact that the study relies on a methodology previously applied in the field of disease control, but never in the field of health financing. Methods: First, we clarify how clusters were defined both in respect of statistical considerations and of local geographical and socio-cultural concerns. Second, we illustrate how households within clusters were sampled. Third, we expound the data collection process and the survey instruments. Finally, we outline the statistical tools to be applied to estimate the impact of CHI. Conclusion: We discuss all design choices both in relation to methodological considerations and to specific ethical and organisational concerns faced in the field. On the basis of the appraisal of our experience, we postulate that conducting relatively sophisticated trials (such as our step-wedge cluster-randomised community-based trial) aimed at generating sound public health evidence, is both feasible and valuable also in low income settings. Our work shows that if accurately designed in conjunction with local health authorities, such trials have the potential to generate sound scientific evidence and do not hinder, but at times even facilitate, the implementation of complex health interventions such as CHI.

Aim Caesarean section deliveries in Ghana increased from 6 to 13% between 2008 and 2014. This current rate is dangerously close to the safe limit suggested by the World Health Organisation (WHO) and is particularly concerning in the absence of a negative correlation between the rising CS rates and neonatal mortality in the country. The research therefore examines the factors correlated with caesarean section delivery in Ghana, with an aim to making research-based policy suggestions to curb the observed trends. Subjects and methods The 2014 Ghana Demographic and Health Survey is employed for the analysis, and a probit model is used to examine the effects of demographic and socioeconomic factors, maternal leave policy and government health institutions on the likelihood of caesarean section deliveries in Ghana. The analysis uses the last births of 1284 women of childbearing age in the country. Results The results indicate that demographic and socioeconomic factors are important determinants of caesarean section deliveries. While antenatal care attendance at government institutions reduces the likelihood of caesarean section, deliveries in government health facilities are more likely to be done by caesarean section. Interestingly, women with previous pregnancy complications are not significantly more likely to have a caesarean section delivery. This might indicate that many caesarean sections performed in the country may be elective and not necessarily medically necessary. Conclusions Child and maternal survivals are often given as justifications for caesarean section deliveries. The absence of a negative relationship between increasing caesarean section rates and neonatal mortality in the country therefore creates some concern.

We do not work with preconceived ideas for solutions, westernbased blueprints or donor-specific protocols. We organize exchange between local and international partners to link local effectiveness to international knowledge. Results and conclusions Application of new insights in implementation theory and complexity management leads to a dynamic process of change, rather than traditional project implementation.

Objective To estimate the out-of-pocket expenditures linked to Road Traffic Injuries in Ouagadougou, Burkina Faso, as well as the prevalence of catastrophic expenditures among those out-of-pocket payments, and to identify the socio-economic determinants of catastrophic expenditures due to Road Traffic Injuries. Methods We surveyed every admission at the only trauma unit of Ouagadougou between January and July 2015 at the time of their admission, 7 days and 30 days later. We estimate a total amount of out-of-pocket expenditures paid by each patient. We considered an expense as catastrophic when it represented 10% at least of the annual global consumption of the patient’s household. We used linear models to determine if socio-economic characteristics were associated to a greater or smaller ratio between out-of-pocket payment and global annual consumption. Findings We surveyed 1323 Road injury victims three times (admission, Days 7 and 30). They paid in average 46,547 FCFA (83.64 US do...

We evaluated the effects and financial costs of two interventions with respect to utilisation of institutional deliveries and other maternal health services in Oyam District in Uganda. We conducted a quasi-experimental study involving intervention and comparable/control sub-counties in Oyam District for 12 months (January-December 2014). Participants were women receiving antenatal care, delivery and postnatal care services. We evaluated two interventions: the provision of (1) transport vouchers to women receiving antenatal care and delivering at two health centres (level II) in Acaba sub-county, and (2) baby kits to women who delivered at Ngai Health Centre (level III) in Ngai sub-county. The study outcomes included service coverage of institutional deliveries, four antenatal care visits, postnatal care, and the percentage of women 'bypassing' maternal health services inside their resident sub-counties. We calculated the effect of each intervention on study outcomes using th...

This paper examines the ways in which poverty and gender inequality impact maternal mortality by creating barriers to maternal healthcare access and utilization. It also analyzes strategies designed to increase utilization to identify best practices. Hundreds of thousands of women die every year in childbirth or from pregnancy-related causes. Virtually all of these maternal deaths occur in poor countries.

Targets and indicators set at the global level are powerful tools that govern health systems in low-income countries. Skilled birth attendance at a health facility is an important indicator for monitoring maternal mortality reduction worldwide. This paper examines how health workers negotiate policy implementation through the translation of clinical care into registries and reports. It does so by analysing the links between the global policy of institutional births and the role of documentation in the provision of birth care in primary health centres in Burkina Faso. Observations of health workers' practices in four primary maternity units (one urban, one semi-urban and two rural) conducted over a 12-week period in 2011-2012 are analysed alongside 14 indepth interviews with midwives and other health workers. The findings uncover the magnitude of reporting demands that health workers experience and the pressure placed on them to provide the 'right' results, in line with global policy objectives. The paper describes the way in which they document inaccurate accounts, for example by completing the labour surveillance tool partograph after birth, thus transforming it into a 'postograph', to adhere to the expectations of health district officers. We argue that the drive for the 'right' numbers might encourage inaccurate reporting practices and it can feed into policies that are incapable of addressing the realities experienced by frontline health workers and patients. The focus on producing indicators of good care can divert attention from actual care, with profound implications for accountability at the health centre level.

Background: Underdeveloped and underused medical laboratories in sub-Saharan Africa negatively affect the diagnosis and appropriate treatment of ailments.Objective: We identified political, disease-related and socio-economic factors that have shaped the laboratory sector in Senegal, Mali and Burkina Faso to inform laboratory-strengthening programmes.Methods: We searched peer-reviewed and grey literature from February 2015 to December 2018 on laboratory and health systems development from colonial times to the present and conducted in-depth interviews with 73 key informants involved in (inter)national health or laboratory policy, organisation, practice or training. This article depended on the key informants’ accounts due to the paucity of literature on laboratory development in francophone West African countries. Literature and interview findings were triangulated and are presented chronologically.Results: Until around 1990 there were a few disease-specific research laboratories; on...

Background: Developing countries with high maternal mortality need to invest in indicators that not only provide information about how many women are dying, but also where, and what can be done to prevent these deaths. The unmet Obstetric Needs (UONs) concept provides this information. This concept was applied at district level in Kenya to assess how many women had UONs and where the women with unmet needs were located. Methods: A facility based retrospective study was conducted in 2010 in Malindi District, Kenya. Data on pregnant women who underwent a major obstetric intervention (MOI) or died in facilities that provide comprehensive Emergency Obstetric Care (EmOC) services in 2008 and 2009 were collected. The difference between the number of women who experienced life threatening obstetric complications and those who received care was quantified. The main outcome measures in the study were the magnitude of UONs and their geographical distribution.

This article presents results from a study that explored the association between community capacity for maternal health promotion and women's use of preventive and curative maternal health services. Implemented in the Republic of Guinea, the intervention aimed to build the capacity of community-level committees to heighten awareness about maternal health risks and to promote use of professional maternal health services throughout pregnancy and childbirth. Data were collected through a population-based survey. A total of 2335 women of reproductive age were interviewed, including 878 with a live birth or stillbirth since the launch of the intervention. An index of community capacity was created to explore the effect of living in a community with strong community-level resources and support for maternal health. Other composite variables were created to measure the content of women's antenatal counselling and their individual exposure to maternal health promotion activities at t...

FOCAL's Health program proposes to use analytical tools in order to produce fact-based evidence about the degree of inequalities and inequities in health and their main determinants among marginalized populations such as Indigenous Peoples and Afro-descendants in Bolivia, Colombia and Peru. This initiative will assist in the identification of policy gaps for the development, discussion and exchange of more accurate health policy ideas. Reform efforts that have been undertaken in Bolivia, and are underway today, are essentially linked with the implementation of new health insurances, conditional cash transfers and decentralization to give local governments more power to deliver more focused and effective policies. Despite these efforts, the results have fallen far short, confining improvements in access and supply of health services to urban and surrounding areas while leaving rural and marginalized populations to face growing levels of inequalities and inequities. Before implementing universal coverage, primary care infrastructure and human • resources, especially in rural areas, could be improved. Women of childbearing age need to be covered and birth control methods could be made • available in order to reduce maternal and neonatal mortality rates.

The estimated per capita annual health expenditure adopted in 2010 Uganda Country health financing review by a combined team of Ministry of Health, WHO Country office and Geneva was US$ 27; the government and donors accounted for half of this and another half came from private out-of-pocket spending. The funding is inadequate compared to the US$ 44 advocated by WHO. Amid political pressure and the exclusion of access to care of more than 50% of the population, user fees were abolished in 2001 from all publicly owned general wings of hospitals and health centres, although they continued to be levied in private wings. The private sector has always charged user fees and continues to do so. As a result, many patients still have difficulty paying bills from hospitals served by private, not-for-profit facilities. Community Health Insurance (CHI) schemes aim to improve financial access to health care. It is voluntary arrangements, organised at the community level, that target individuals employed in the informal sector. The schemes run on a non-profit basis and apply the basic principle of risk sharing with community participation in design and management. The ruling party's presidential election manifesto (2006-20u) includes using CHI as a way to provide protection against catastrophic health expenditures, but the number of schemes and persons covered by CHI remains small in Uganda. The 2010/n-2019/20 national health policy lists CHI as a financing mechanism for the health sector. Currently, the health sector is in the process of drafting a law to provide for CHI development. No studies in Uganda or the East African region have explored the possible reasons for low enrolment in CHI. Uganda's interest in promoting CHI and abolishing user fees for publicly owned health units requires examination. The perceptions of the communities in which the schemes exist have never been fully explored and little is known about the perceptions and knowledge of CHI held by scheme members, managers of district health services and policy-makers. The aim of this thesis is to contribute to the understanding of CHI, both in general and in Uganda specifically. The general objective is to investigate the obstacles and prospects for CHI schemes in Uganda. The specific objectives are: (1) to study demand and supply side factors to explain the low levels of enrolment in existing CHI schemes; (2) to investigate the perceptions of CHI held by those enrolled and those not enrolled in the [126]

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Background: This paper investigates knowledge of Community Health Insurance (CHI) and the perception of its relevance by key policy makers and health service managers in Uganda. Community Health Insurance schemes currently operate in the private-not-for-profit sector, in settings where church-based facilities function. They operate in a wider policy environment where user fees in the public sector have been abolished. Methods: Semi-structured interviews were conducted during the second half of 2007 with District Health Officers (DHOs) and senior staff of the Ministry of Health (MOH). The qualitative data collected were analyzed using the framework method, facilitated by EZ-Text software. Results: There is poor knowledge and understanding of CHI activities by staff of the MOH headquarters and DHOs. However, a comparison of responses reveals a relatively high level of awareness of CHI principles among DHOs compared to that of MOH staff. All the DHOs in the districts with schemes had a good understanding of CHI principles compared to DHOs in districts without schemes. Out-of-pocket expenditure remains an important feature of health care financing in Uganda despite blanket abolition of user fees in government facilities. Conclusion: CHI is perceived as a relevant policy option and potential source of funds for health care. It is also considered a means of raising the quality of health care in both public and private health units. To assess whether it is also feasible to introduce CHI in the public sector, there is an urgent need to investigate the willingness and readiness of stakeholders, in particular high level political authorities, to follow this new path. The current ambiguity and contradictions in the health financing policy of the Uganda MOH need to be addressed and clarified.

Background Despite the promotion of Community Health Insurance (CHI) in Uganda in the second half of the 90's, mainly under the impetus of external aid organisations, overall membership has remained low. Today, some 30,000 persons are enrolled in about a dozen different schemes located in Central and Southern Uganda. Moreover, most of these schemes were created some 10 years ago but since then, only one or two new schemes have been launched. The dynamic of CHI has apparently come to a halt. Methods A case study evaluation was carried out on two selected CHI schemes: the Ishaka and the Save for Health Uganda (SHU) schemes. The objective of this evaluation was to explore the reasons for the limited success of CHI. The evaluation involved review of the schemes' records, key informant interviews and exit polls with both insured and non-insured patients. Results Our research points to a series of not mutually exclusive explanations for this under-achievement at both the demand an...

Background: Burkina Faso, like many low and middle income countries, has been taking a range of actions to address its poor maternal and neonatal health indicators. In 2006 the government introduced an innovative national subsidy scheme for deliveries and emergency obstetric care in public facilities. This article reports on a complex evaluation of this policy, carried out 5 years after its introduction, which examined its effects on utilisation, quality of care, equity and the health system as a whole, as well as its cost and sustainability. Methods: The evaluation was carried out in six purposively selected districts, as well as at national level, using a case study approach. Data sources included: national and district routine and survey data, household interviews with women who had recently given birth, data extraction from hospital and medical records, and key informant and health worker interviews. Results: The underlying secular trend of a 1 % annual increase in the facility-based delivery rate (1988-2010) was augmented by an additional 4 % annual increase from 2007 onwards (after the policy was introduced), especially in rural areas and amongst women from poor households. The absence of baseline quality of care data made it difficult to assess the impact of the policy on quality of care, but hospitals with the best level of implementation of the subsidy offered higher quality of care (as measured by health care near-misses), so there is no evidence of a negative impact on quality (as is often feared). Similarly, there is little evidence of unintended negative effects on untargeted services. Household payments for facility-based deliveries have reduced significantly, compared with payments before the policy, and the policy as a whole is affordable, costing about 2 % of total public health expenditure. Concerns include that the amounts paid by households are higher than the rates set by the policy, and also that 7 % of households still say that they cannot afford to pay. Wealthier women have higher utilisation of services, as before, and the policy of fully exempting indigents is not being put into practice. Conclusions: These findings highlight the importance of maintaining the subsidy policy, given the evidence of positive outcomes, but they also point out areas where attention is needed to ensure the poor and most vulnerable population benefit fully from the policy.

background The Free Deliveries and Caesarean Policy (FDCP) entitles all women in Morocco to deliver free of charge within public hospitals. This study assesses the policy's effectiveness by analysing household expenditures related to childbirth, by delivery type and quintile. methods Structured exit survey of 973 women in six provinces at five provincial hospitals, two regional hospitals, two university hospitals and three primary health centres with maternity units. results Households reported spending a median of US$ 59 in total for costs inside and outside of hospitals. Women requiring caesareans payed more than women with uncomplicated deliveries (P < 0.0001). The median cost was US$45 for a uncomplicated delivery, US$50 for a complicated delivery and US$65 for a caesarean section. The prescription given upon exiting the hospital comprised 62% of the total costs. Eighty-eight per cent of women from the poorest quintiles faced catastrophic expenditures. The women's perception of their hospital stay and the FDCP policy was overwhelmingly positive, but differences were noted at the various sites. conclusion The policy has been largely but not fully effective in removing financial barriers for delivery care in Morocco. More progress should also be made on increasing awareness of the policy and on easing the financial burden, which is still borne by households with lower incomes.

The ratio of maternal morbidity and mortality in developing countries is high. The World Health Organization (WHO) and public health specialists promote case review audits as a means of improving quality of obstetric care. This refl ects the need for high reactivity in health personnel's management of obstetric complications. Within an action-research programme in Burkina Faso, a trial of case review audits was implemented in a maternity ward. This was designed to help health personnel bett er align their practice with clinical standards and to enable more consideration of pregnant women's needs. Social anthropologists were involved in these case review audits in order to collect data about pregnant women's lifestyles and circumstances. They also worked to train health personnel to conduct interviews. Although it is important to take account of women's circumstances within audit sessions, conducting interviews in 'anthropological ways' (at women's homes, with observations) is time consuming and may sometimes be bett er replaced with interviews in hospital contexts. Anthropologically informed interviews may pinpoint socioeconomic situations as key reasons for problems in healthcare, but health personnel are usually powerless to address these. However, anthropology contributes an awareness of the relevance of these issues for broader healthcare planning.

The studies measured Out-of-Pocket Expenditure (OOPE) for hospital births previously suffer from serious data limitations. To overcome such limitations, we designed a hospital-based study for measuring the levels and factors of OOPE on maternity care for hospital births by its detailed components. Data were collected from women for non-complicated deliveries 24-h before the survey and complicated deliveries 48-h prior to the survey at the hospital settings in Uttar Pradesh, India during 2014. The simple random sampling design was used in the selection of respondents. Bivariate analyses were used to estimate mean expenditure on Antenatal care services (ANCs), Delivery care and Total Maternity Expenditure (TME). Multivariate linear regression was employed to examine the factor associated with the absolute and relative share of expenditure in couple&#39;s annual income on ANCs, delivery care, and TME. The findings show that average expenditure on maternal health care is high ($155) in ...

Background: Cardiovascular diseases (CVD) are a leading contributor to the burden of disease in low-and middleincome countries. Guidelines for CVD prevention care in low resource settings have been developed but little information is available on strategies to implement this care. A community health insurance program might be used to improve patients' access to care. The operational research project "QUality Improvement Cardiovascular care Kwara-I (QUICK-I)" aims to assess the feasibility of CVD prevention care in rural Nigeria, according to international guidelines, in the context of a community based health insurance scheme. Methods/Design: Design: prospective observational hospital based cohort study. Setting: a primary health care centre in rural Nigeria. Study population: 300 patients at risk for development of CVD (patients with hypertension, diabetes, renal disease or established CVD) who are enrolled in the Hygeia Community Health Plan. Measurements: demographic and socioeconomic data, physical and laboratory examination, CVD risk profile including screening for target organ damage. Measurements will be done at 3 month intervals during 1 year. Direct and indirect costs of CVD prevention care will be estimated. Outcomes: 1) The adjusted cardiovascular quality of care indicator scores based on the "United Kingdom National Health Services Quality and Outcome Framework". 2) The average costs of CVD prevention and treatment per patient per year for patients, the clinic and the insurance company. 3) The estimated net health care costs of standard CVD prevention care per quality-adjusted life year gained. Analysis: The primary outcomes, the score on CVD quality indicators and cost data will be descriptive. The quality scores and cost data will be used to describe the feasibility of CVD prevention care according to international guidelines. A cost-effectiveness analysis will be done using a Markov model. Discussion: Results of QUICK-I can be used by policy makers and professionals who aim to implement CVD prevention programs in settings with limited resources. The context of the insurance program will provide insight in the opportunities community health insurance may offer to attain sustainable chronic disease management programs in low resource settings. Trial registration: This protocol has been registered at ISRCTN, ID number: ISRCTN47894401.

About 20 years after initial calls for the introduction of user fees in health systems in sub-Saharan Africa, a growing coalition is advocating for their removal. Several African countries have abolished user fees for health care for some or all of their citizens. However, fee-for-service health care delivery remains a primary health care funding model in many countries in sub-Saharan Africa. Although the impact of user fees on utilization of health services and household finances has been studied extensively, further research is needed to characterize the multi-faceted health and social problems associated with charging user fees. This ethnographic study aims to identify consequences of user fees on gender inequality, food insecurity, and household decision-making for a group of women living in poverty. Ethnographic life history interviews were conducted with 24 women in Yirimadjo, Mali in 2007. Purposive sampling selected participants across a broad socioeconomic spectrum. Semi-structured interviews addressed participants' past medical history, socioeconomic status, social and family history, and access to health care. Interview transcripts were coded using the guiding analytical framework of structural violence. Interviews revealed that user fees for health care not only decreased utilization of health services, but also resulted in delayed presentation for care, incomplete or inadequate care, compromised food security and household financial security, and reduced agency for women in health care decision making. The effects of user fees were amplified by conditions of poverty, as well as gender and health inequality; user fees in turn reinforced the inequalities created by those very conditions. The qualitative data reveal multi-faceted health and socioeconomic effects of user fees, and illustrate that user fees for health care may impact quality of care, health outcomes, food insecurity, and gender inequality, in addition to impacting health care utilization and household finances. As many countries consider user fee abolition policies, these findings indicate the need to create a broader evaluation frameworkdone that can measure the health and socioeconomic impacts of user fee polices and of their removal.

UNICEF (2009) has stated that 80% of maternal deaths could be avoided if known interventions were implemented. Thus, in the fight against maternal mortality, many voices have been raised deploring the fact that strategies known to be effective a priori are not being implemented, particularly in Africa (De Brouwere & Van Lerberghe, 2001; United Nations Secretary-General, 2010). One recommended intervention is to encourage women to use qualified personnel for deliveries. Proper care at deliveries could reduce the risks of maternal mortality and morbidity by 95% (Graham, Bell, & Bullough, 2001; World Health Organization, 2010a). Studies have shown that the financial barrier is one of several reasons for women's low recourse to qualified personnel for assisted deliveries (Nanda, 2002). Therefore it is now recommended that user fees for deliveries be eliminated (African Union, 2010; Richard, Witter, & de Brouwere, 2010; World Health Organization, 2010b). However, it is not enough to follow internationally recognized recommendations by formulating public policies; these policies must also be effectively implemented, since, ''if implementation fails, everything fails'' (Chen, 2004). Indeed, other authors have asserted that ''many evidence-based innovations fail to produce results when transferred to communities in the global south, largely because their implementation is untested, unsuitable or incomplete'' (Madon, Hofman, Kupfer, & Glass, 2007). Moreover, meta-analyses have shown that the efficacy of interventions is generally subject to multiple distortion factors related to implementation, often in excess of 50% (Durlak & DuPre, 2008). Unfortunately, only 4% of publications on public policy implementation between 1933 and 2003 concern Africa (Saetren, 2005), and few of those were concerned with issues of equity in health (Gilson & Raphaely, 2008). In addition, scarcely any studies on health promotion or health policies in low-income countries refer directly to concepts and theories used in the study of public policies (Breton & De Leeuw, 2011; Gilson & Raphaely, 2008). 2. Context and intervention In Burkina Faso, 46% of the population is considered to live below the poverty threshold, which is 0.41 Euros per day. It has Evaluation and Program Planning 36 (2013) 145-152