Ensuring financial access to emergency obstetric care: Three years of experience with Obstetric Risk Insurance in Nouakchott, Mauritania

Nouakchott Safe Motherhood Project, Direction Régionale des Affaires sanitaires et sociales, Nouakchott, Mauritania.
International Journal of Gynecology & Obstetrics (Impact Factor: 1.54). 12/2007; 99(2):183-90. DOI: 10.1016/j.ijgo.2007.07.006
Source: PubMed


The high cost of emergency obstetric care (EmOC) is a catastrophic health expenditure for households, causing delay in seeking and providing care in poor countries.
In Nouakchott, the Ministry of Health instituted Obstetric Risk Insurance to allow obstetric risk sharing among all pregnant women on a voluntary basis. The fixed premium (US$21.60) entitles women to an obstetric package including EmOC and hospital care as well as post-natal care. The poorest are enrolled at no charge, addressing the problem of equity.
95% of pregnant women in the catchment area (48.3% of the city's deliveries) enrolled. Utilization rates increased over the 3-year period of implementation causing quality of care to decline. Basic and comprehensive EmOC are now provided 24/7. The program has generated US$382,320 in revenues, more than twice as much as current user fees. All recurrent costs other than salaries are covered.
This innovative sustainable financing scheme guarantees access to obstetric care to all women at an affordable cost.

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    • "This further widens gaps in financial protection, since the private/CHAM facilities collect out-of-pocket payments. It should be noted that although the community perceived better quality of care at private facilities, in line with what was reported in other studies within SSA settings [52,53], the reality of such facilities actually providing high standard quality of care may differ substantially. In rural Malawi, for instance, probably only the CHAM facilities have a better capacity in terms of infrastructure, medical equipment and personnel than most public facilities. "
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    ABSTRACT: Background In sub-Saharan Africa, universal health coverage (UHC) reforms have often adopted a technocratic top-down approach, with little attention being paid to the rural communities’ perspective in identifying context specific gaps to inform the design of such reforms. This approach might shape reforms that are not sufficiently responsive to local needs. Our study explored how rural communities experience and define gaps in universal health coverage in Malawi, a country which endorses free access to an Essential Health Package (EHP) as a means towards universal health coverage. Methods We conducted a qualitative cross-sectional study in six rural communities in Malawi. Data was collected from 12 Focus Group Discussions with community residents and triangulated with 8 key informant interviews with health care providers. All respondents were selected through stratified purposive sampling. The material was tape-recorded, fully transcribed, and coded by three independent researchers. Results The results showed that the EHP has created a universal sense of entitlements to free health care at the point of use. However, respondents reported uneven distribution of health facilities and poor implementation of public-private service level agreements, which have led to geographical inequities in population coverage and financial protection. Most respondents reported affordability of medical costs at private facilities and transport costs as the main barriers to universal financial protection. From the perspective of rural Malawians, gaps in financial protection are mainly triggered by supply-side access-related barriers in the public health sector such as: shortages of medicines, emergency services, shortage of health personnel and facilities, poor health workers’ attitudes, distance and transportation difficulties, and perceived poor quality of health services. Conclusions Moving towards UHC in Malawi, therefore, implies the introduction of appropriate interventions to fill the financial protection gaps in the private sector and the access-related gaps in the public sector and/or an effective public-private partnership that completely integrates both sectors. Current universal health coverage reforms need to address context specific gaps and be carefully crafted to avoid creating a sense of universal entitlements in principle, which may not be effectively received by beneficiaries due to contextual and operational bottlenecks.
    BMC Health Services Research 05/2014; 14(1):234. DOI:10.1186/1472-6963-14-234 · 1.71 Impact Factor
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    • "Ouma et al [41] found a significantly greater proportion of women in the intervention areas rated the quality of ANC services as very satisfactory, despite the worsening in the measures of quality care following staff training. In the trial of obstetric risk insurance in Mauritania[21] utilisation of intervention facilities increased substantially despite declines in the clinical quality of both ANC and delivery care. "
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    ABSTRACT: Efforts to scale-up maternal and child health services in lower and middle income countries will fail if services delivered are not of good quality. Although there is evidence of strategies to increase the quality of health services, less is known about the way these strategies affect health system goals and outcomes. We conducted a systematic review of the literature to examine this relationship. We undertook a search of MEDLINE, SCOPUS and CINAHL databases, limiting the results to studies including strategies specifically aimed at improving quality that also reported a measure of quality and at least one indicator related to health system outcomes. Variation in study methodologies prevented further quantitative analysis; instead we present a narrative review of the evidence. Methodologically, the quality of evidence was poor, and dominated by studies of individual facilities. Studies relied heavily on service utilisation as a measure of strategy success, which did not always correspond to improved quality. The majority of studies targeted the competency of staff and adequacy of facilities. No strategies addressed distribution systems, public-private partnership or equity. Key themes identified were the conflict between perceptions of patients and clinical measures of quality and the need for holistic approaches to health system interventions. Existing evidence linking quality improvement strategies to improved MNCH outcomes is extremely limited. Future research would benefit from the inclusion of more appropriate indicators and additional focus on non-facility determinants of health service quality such as health policy, supply distribution, community acceptability and equity of care.
    PLoS ONE 12/2013; 8(12):e83070. DOI:10.1371/journal.pone.0083070 · 3.23 Impact Factor
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    • "Although these indirect evaluations have contributed to identifying groups who likely fail to receive needed care, utilization-based estimations of disadvantage are potentially problematic for at least two reasons. First, having utilized is not always synonymous of abilities to afford healthcare because users may have engaged themselves into catastrophic expenses1 to acquire care [23,38-41]. Second, non-utilization is not necessarily due to inability to use because individuals may prefer alternative sources of care [23,42]. "
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    ABSTRACT: In sub-Saharan Africa, women must overcome numerous barriers when they need modern healthcare. Respect of gender norms within the household and the community may still influence women's ability to obtain care. A lack of gender-sensitive instruments for measuring women's ability to overcome barriers compromises attempts to adequately quantify the burden and risk of exclusion they face when seeking modern healthcare. The aim of this study was to create and validate a synthetic measure of women's access to healthcare from a publicly available and possibly internationally comparable population-based survey. Seven questionnaire items from the Burkina Faso 2003 DHS were combined to create the index. Cronbach's alpha coefficient was used to test the reliability of the index. Exploratory factor analyses (EFA) and confirmatory factor analyses (CFA) were applied to evaluate the factorial structure and construct validity of the index while taking into account the hierarchical structure of the data. The index has a Cronbach's alpha of 0.75, suggesting adequate reliability. In EFA, three correlated factors fitted the data best. In CFA, the construct of perceived ability to overcome barriers to healthcare seeking emerged as a second-order latent variable with three domains: socioeconomic barriers, geographical barriers and psychosocial barriers. Model fit indices support the index's global validity for women of reproductive age in Burkina Faso. Evidence for construct validity comes from the finding that women's index scores increase with household living standard. The DHS items can be combined into a reliable and valid, gender-sensitive index quantifying reproductive-age women's perceived ability to overcome barriers to healthcare seeking in Burkina Faso. The index complies conceptually with the sector-cross-cutting capability approach and enables measuring directly the perceived access to healthcare. Therefore it can help to improve the design and evaluation of interventions that aim to facilitate healthcare seeking in this country. Further analyses may examine how far the index applies to similar contexts.
    BMC Public Health 02/2012; 12(1):147. DOI:10.1186/1471-2458-12-147 · 2.26 Impact Factor
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