Financial implications of skilled attendance at delivery in Nepal

Abstract

Summaryobjective To measure costs and willingness-to-pay for delivery care services in 8 districts of Nepal. method Household costs were used to estimate total resource requirements to finance: (1) the current pattern of service use; (2) all women to deliver in a health facility; (3) skilled attendance at home deliveries with timely referral of complicated cases to a facility offering comprehensive obstetric services.results The average cost to a household of a home delivery ranged from 410 RS ($5.43) (with a friend or relative attending) to 879 RS ($11.63) (with a health worker). At a facility the average fee for a normal delivery was 678 RS ($8.97). When additional charges, opportunity and transport costs were added, the total amount paid exceeded 5300 RS ($70). For a caesarean section the total household cost was more than 11 400 RS ($150). Based on these figures, the cost of financing current practice is 45 RS ($0.60) per capita. A policy of universal institutional delivery would cost 238 RS ($3.15) per capita while a policy of skilled attendance at home with early referral of cases from remote areas would cost around 117 RS ($1.55) per capita. These are significant sums in the context of a health budget of about 400 RS ($5) per capita.conclusions The financial cost of developing a skilled attendance strategy in Nepal is substantial. The mechanisms to direct funding to women in need must to be improved, pricing needs to be more transparent, and payment exemptions in public facilities must be better financed if we are to overcome both supply and demand-side barriers to care seeking.

The Experience of Ghana in Implementing a User Fee Exemption Policy to Provide Free Delivery Care

“…Nepal, for example, is piloting a policy that combines subsidies for all deliveries with free deliveries and assistance with costs such as transport for women in poorer regions. 21,22 There is experience in Yunnan, China, and Bangladesh in using vouchers that entitle poor women to free delivery services. 23 In Bolivia, a social insurance scheme, which provides free care for pregnant women and under-fives, has increased utilisation, especially by the poor.…”

“…Given the relatively high cost-recovery rates in Ghana and reasonable geographic access to services, the emphasis on reducing fees was appropriate, whereas in Nepal, transport costs constitute the largest cost element for households in accessing maternal care. 22 Ghana's experience suggests that where facilities are understaffed, as in much of subSaharan Africa, they should be closely involved in the development of policies such as these and a package of incentives provided for staff to deliver quality care. The health worker survey in this evaluation found that although very few direct financial incentives were provided as part of the delivery exemption policy, the overall increase in pay as part of wider pay reforms in the public sector compensated for increased hours of work for different types of staff.…”

Improving access to maternity services: an overview of cash transfer and voucher schemes in South Asia

“…1,24,26 Of these obstacles, the cost of services and other financial barriers are perceived by poor women as one of the major reasons against delivering in a health facility. 2,3,27 Health policy and decision-makers have therefore focused attention on mechanisms to address the cost barriers that women face.…”

“…3,12 Skilled providers are also incentivised for facility deliveries and for home deliveries, given that difficult terrain in Nepal renders many facilities inaccessible. 27,36 Health providers pay women in cash directly upon discharge. Rather than target the scheme towards the poorest, the government chose universal targeting, ostensibly for equity though it is also easier to manage and popular politically.…”

Direct Cost of Maternity-care Services in South Delhi: A Community Survey

“…Also, knowledge of maternity-related expense and its determinants is useful for health authorities to focus public resources and target financial assistance or exemption guidelines towards the 'most needy' (7). Expenses for maternal and neonatal care in antepartum, intrapartum and postpartum services has been well-documented in several studies (7-13) conducted in developed countries and in South Asian countries (14)(15)(16)(17), allowing for more efficient use of resources. However, there is a paucity of such data from India.…”