National fee exemption schemes for deliveries: comparing the recent experiences of Ghana and Senegal
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Continuing high maternal mortality ratios, especially in Africa, and high discrepancies between richer and poorer households in relation to access to maternal health care and maternal health status have focussed attention on the importance of reducing financial barriers to skilled care. This article compares the findings of two studies on national policies exempting women from user fees for deliveries, conducted in Ghana in 2005-6 and in Senegal in 2006-7. The evaluations used a combination of research methods, including key informant interviews, household surveys, financial flows tracking, health worker incentive surveys, confidential enquiry, clinical case note record extraction, community level interviews and focus group discussions. The detailed findings from each evaluation are presented, followed by the broad lessons learnt from these similar (but not identical) policies. The policies shared goals, and both were implemented in poorer regions initially but then scaled up, using national resources. They demonstrate the potential of fee exemption policies to increase utilisation. The cost per additional assisted delivery was $62 (average) in Ghana and $21 (normal delivery) and $467 (caesarean section) in Senegal. There was also some evidence of reductions in inequalities of access.