Karen Van der Veken (Maternal and Reproductive Health Unit, Public Health Department,  ITM)

In this blog post, Karen Van der Veken (ITM) reflects on a recent FEMHealth workshop at ITM.  She also assesses the shifting women’s health agenda at the global level.

Group picture

From 2 to 4 September, we welcomed our colleagues from the FEMHealth project for a workshop at the Institute of Tropical Medicine in Antwerp. It has been a fruitful workshop, so we see this week’s newsletter as an excellent opportunity to share what the FEMHealth project is about, and to give some preliminary results that have been discussed during this workshop. ITM’s partners in FEMHealth are the London School for Tropical Medicine and Hygiene, the University of Aberdeen, AFRICSanté (Burkina Faso), CERRHUD (Benin), CAREF (Mali), INAS (Morocco) et IRSS (Burkina Faso). Fabienne Richard, Bruno Marchal, Vincent De Brouwere, Dominique Dubourg and Karen Van der Veken take part in this project for ITM.

The FEMHealth project – short for Assessing the impact of fee exemption on maternal health in West Africa and Morocco: new tools, new knowledge – is part of the Seventh Framework Programme (FP7) of the European Union. This 3-year research project started in 2011 and its outputs will be discussed at a meeting of the Community of Practice “Financial access to health services”, to be held in Ouagadougou from 25 to 29 November 2013.

The objectives of FEMHealth are three-fold:

1)      to develop new methodological approaches for the evaluation of complex interventions in low income countries

2)      to improve the health of mothers and their newborns by performing comprehensive evaluations of the impact, cost and effectiveness of the removal of user fees for delivery care and Emergency Obstetric Care on maternal and neonatal health outcomes and service quality

3)      to improve the communication of this evidence to policy-makers and other stakeholders

The timing of FEMHealth is, of course, not a coincidence.  After the publication of country progress reports on the Millennium Development Goals (MDGs), to be achieved in 2015, it became clear that the 5th MDG showed little or insufficient progress. Mainly sub-Saharan African countries were found to lag behind. MDG 5, aiming to reduce maternal mortality drastically – among other measures through increased coverage of skilled assistance during delivery – and MDG 4 with decreased child and infant mortality as objective, are closely linked to the aim to reach universal health coverage. In an attempt to accelerate the progress on the 4th and 5th MDGs, several African countries have implemented fee exemption policies, targeting or including maternal health care services. Most of these policies aim at increasing the offer of high quality prenatal, obstetrical and postnatal care, and at making these services more accessible, especially for the poorest – often also those living furthest away from the health facilities. However, while the efficiency of these policies has often been the subject of evaluation,  very few studies have focused so far on the implementation process and the unintended, possibly negative, effects on both non-targeted services and population groups, and the target group itself.

Four focal countries are involved in the FEMHealth research project. Three of these countries belong to francophone West Africa – Benin, Burkina Faso and Mali – and one is situated in the Maghreb region, Morocco. All four countries introduced policies to remove fees  for (or largely subsidize) deliveries and caesarean sections and expressed a strong commitment to evaluating their reforms. None of them has as yet got a full evaluation of their policies. Policymakers from these countries worked in close collaboration with FEMHealth researchers. The research was organized along three thematic work packages: policy, local health systems and quality of care. Within each work package, research tools were developed or refined and research has been conducted. The teams responsible for the different work packages are currently refining and adapting the tools for other contexts and preparing the dissemination of the results.

Preliminary analyses of the abundant quantitative and qualitative data collected during this project indicate some methodological difficulties. These include the creation of tools that aim to capture the differences of impact in different sites within the same country, as well as tools to allow comparison between the four countries, each with a different policy.

Initial results from the POlicy Effect Mapping (POEM) studies and the realist case studies on policy implementation (carried out by work package 3 under the responsibility of the ITM team) show how effects of the (national) fee exemption policies are not only influenced by the policy design and its implementation modalities, but also to a large extent by factors at the local health system level and the context. The absorption capacity of the system, resource availability and power relations between health providers, community, managers and politicians interact constantly in the implementation process.

The existing literature on fee exemption policies focused mainly on good practices for policy implementation, based on the logic that the accompanying measures (such as communication towards the targeted public and health work force, guidelines and training for implementers, estimation of expected increases in service utilization and concomitant budget allocation for drugs, equipment, human resources, incentives…) will determine the degree of implementation. The FEMHealth project, however, found that whether a fee exemption policy will be adopted, ignored or adapted to the local context (in a positive or negative manner), depends very much on context-specific factors, timing, the nature of the motivation of the implementing actors (managers, service providers), and above all, on the  presence of effective stewardship which is able to align all actors’ interests with the public interest and to adapt the introduced policy to local and perceived health needs.

The outcome of fee exemption policies in terms of maternal and neonatal health status is difficult to assess. Maternal mortality is notoriously difficult to measure and financial barriers are not the sole barriers to qualitative health care. FEMHealth has confirmed that fee abolition without accompanying measures to increase the availability of care (including transport opportunities) and to preserve and increase the quality of care, may in the best scenario increase service utilization (including emergency interventions like caesarean sections), without necessarily improving the health outcomes for mothers and newborns. Partly depending on the reimbursement modalities and potential opportunistic behavior of health staff, a variety of perverse effects of these (potentially well intentioned) policies exist: health structures inducing the utilization of caesarean sections because they represent a financial advantage, service providers demanding informal payments in return for qualitative care, or worse, as a condition for treatment, or simply the users of the health system turning to private sectors in a desperate attempt to be treated correctly. This sometimes even leads to catastrophic household expenditure – the exact opposite of the policy’s main objective.

The dissemination of the results of FEMHealth aims at informing the discussion between technical and implementing partners in the preparatory stages of fee exemption policies in other countries. The hope is that this will lead to better design of the policies, including reimbursement modalities and sustainable financing methods, as well as enhancing monitoring and evaluation activities in order to effectively reach the intended positive effects of fee abolition for maternal health.

One might wonder though whether targeted fee exemption policies will live a long life. In an ideal world, targeted exemption policies will be replaced by subsidized insurance schemes. However,  recent experiences have shown that implementing UHC is even more complicated than implementing targeted fee exemption policies. Moreover, now that the debate on the post-MDG era is gaining momentum, the international community seems to be in need of some encouragement to continue the investment in maternal and neonatal health, which has shown insufficient progress despite years of increased financial and operational efforts. Some large institutional donors, traditionally prioritizing maternal and child health care aid in their budgets, are leaving countries where maternal mortality remains unacceptably high – e.g. Haiti where both UNFPA and CIDA will have withdrawn by 2014. It tastes somewhat  bitter that where development progress is not clear or rapid enough, objectives and priorities are reset before they get a fair chance to be reached. Donor-dependent NGOs copy-paste this attitude and hide behind carefully crafted logical frameworks where only those results that will be achieved for sure, are proposed.

Earlier this week, the World Health Organization set a new agenda in a special theme issue of the WHO Bulletin: women’s health beyond reproduction. The prevention and control of non-communicable diseases, including breast cancer and chronic diseases, now rightly receive the attention they deserve since many years. Several countries, especially those with significant progress on MDG 5, are confronted with a higher mortality and morbidity burden related to NCDs than to reproductive health matters. Priorities should indeed be reset according to actual and perceived needs. However, we should not forget that universally accepted objectives on maternal and neonatal health outcomes are far from achieved. It is too soon for development partners and external donors to disengage.

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