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Assessing the impact of fee exemption on maternal health in West Africa and Morocco: new tools, new knowledge

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Evaluating maternal health policy interventions

Many countries have introduced fee exemptions or subsidies to improve access to maternal health care, but few have been holistically evaluated. EU-funded research has addressed this gap by developing research methodologies that lead to stronger evidence and improved dissemination, contributing to better maternal and neonatal outcomes.

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Several African countries have introduced a policy of user fee exemption for normal deliveries, Caesarean sections and emergency obstetric care (EmOC). The FEMHEALTH project worked to boost research on policy design and implementation, stronger evidence and improved dissemination. The goal was to provide better approaches to evaluation of interventions in resource-poor countries, and for examination of the impact, cost and effectiveness of removing user fees or introducing subsidies for maternal health care. Focusing on francophone west Africa, the consortium comprised eight partners from six countries and offered a wide range of disciplines as well as sharing extensive experience in evaluation of policy making and policy implementation in healthcare. They conducted literature reviews, developed and used advanced relevant research tools, and drew up situation analysis documents for each study country. To aid communication and dissemination, they also supported the establishment of a virtual ‘community of practice’, which continues to share knowledge on financial access to health services in Africa. Specifically, research centred on national policies designed to improve access to obstetric care in Burkina Faso, Benin, Mali and Morocco. Partners sought to understand the origins, financing, implementation and effects of these policies that introduced subsidies or fee exemptions for deliveries and caesareans. Employing mixed methods research in four to six study sites within each country, FEMHEALTH conducted interviews, analysed data and used a realist evaluation approach to understand the determinants of differences in policy implementation, as well as examining effects on the wider health system and any unanticipated consequences. The project found a narrowing of inequalities for the countries with survey data (Mali did not have recent data) and a substantial reduction in household payments for targeted services. No major impact on the overall health system was observed, and FEMHEALTH determined the financial burden of the policies, funded from national resources, to be manageable. Another finding related to wide-ranging outcomes in different contexts, underlining the importance of context and the institutional and organisational frameworks into which policies are introduced. Although the policies have only recently been introduced, the project has shown that they likely have played a part in continued improvements, together with other positive changes and investments. However, there is still much to be done to increase the financial protection that these policies can offer. FEMHEALTH outcomes promise a better understanding of the positive or negative impact of policies, in the region of interest, on maternal health outcomes, quality of care and access to emergency care. Findings have been shared extensively with policymakers and stakeholders, enabling them to analyse and improve health policy and relevant financing design and implementation.

Keywords

Maternal health, fee exemption, caesarean sections, obstetric care, policy implementation, West Africa

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