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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    • "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.
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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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