The effect of user fee exemption on the utilization of maternal health care at mission health facilities in Malawi

Financing for equity for women's, children's and adolescents' health in low- and middle-income countries: A scoping review

Over the past few decades, the world has witnessed considerable progress in women's, children's and adolescents' health (WCAH) and the Sustainable Development Goals (SDGs). Yet deep inequities remain between and within countries. This scoping review aims to map financing interventions and measures to improve equity in WCAH in low- and middle-income countries (LMICs). This scoping review was conducted following Joanna Briggs Institute (JBI) guidance for conducting such reviews as well as the PRISMA Extension for Scoping Reviews (PRISMA-ScR) for reporting scoping reviews. We searched Medline, PubMed, EMBASE and the World Health Organization's (WHO) Global Index Medicus, and relevant websites. The selection process was conducted in duplicate and independently. Out of 26 355 citations identified from electronic databases, relevant website searches and stakeholders' consultations, 413 studies were included in the final review. Conditional cash transfers (CCTs) (22.3%), health insurance (21.4%), user fee exemptions (18.1%) and vouchers (16.9%) were the most reported financial interventions and measures. The majority were targeted at women (57%) and children (21%) with others targeting adolescents (2.7%) and newborns (0.7%). The findings highlighted that CCTs, voucher programs and various insurance schemes can improve the utilization of maternal and child health services for the poor and the disadvantaged, and improve mortality and morbidity rates. However, multiple implementation challenges impact the effectiveness of these programmes. Some studies suggested that financial interventions alone would not be sufficient to achieve equity in health coverage among those of a lower income and those residing in remote regions. This review provides evidence on financing interventions to address the health needs of the most vulnerable communities. It can be used to inform the design of equitable health financing policies and health system reform efforts that are essential to moving towards universal health coverage (UHC). By also unveiling the knowledge gaps, it can be used to inform future research on financing interventions and measures to improve equity when addressing WCAH in LMICs.

Utilization of maternal health facilities and rural women's well-being: towards the attainment of sustainable development goals

BACKGROUND

The sustenance of any household is tied to the well-being of the mother's health before, during, and after pregnancy. Maternal health care has continued a downward slope, increasing maternal mortality in rural communities in Nigeria. Presently, few empirical findings connect maternal healthcare facilities' use to mothers' well-being in Nigeria. Using maternal health facilities and the well-being of rural women is crucial in achieving the United Nations' Sustainable Development Goals 1, 2, and 3 (No poverty, zero hunger, good health, and well-being).

OBJECTIVE

The objective of the study was to examine the level of maternal healthcare utilization and its effect on mothers' well-being status among mothers in rural Nigeria.

METHODS

In this study, secondary data extracted from the Nigeria's 2018 National Demographic Health Survey was used. Data was analyzed with Multiple correspondence analysis, Fuzzy set analysis, and Extended ordered logit model.

RESULTS

Women in rural Nigeria were moderate users of maternal health care services and had moderate well-being indices (0.54 ± 0.2, 0.424 ± 0.2, respectively). Mothers' moderate well-being status was increased by using maternal health care facilities, having a larger household, and having mothers who worked exclusively in agriculture.

CONCLUSION

We concluded that mothers in rural Nigeria use maternal healthcare facilities moderately, and their well-being level was improved using maternal healthcare facilities. Therefore, Nigeria's Ministry of Health should raise awareness about the vitality of mothers using health care services before, during, and after pregnancy. In order to promote greater female participation in full-scale agricultural production, it is imperative for the Nigerian government to allocate substantial resources in the form of subsidies and incentives. The Nigerian government should source these resources from various channels, including expanded development cooperation. Additionally, policymakers should focus on designing developmental programmes specifically tailored for rural households and the health sector.

Perceptions and experiences of intravenous iron treatment for anaemia in pregnancy in Malawi: a formative qualitative study

Background

The study objective was to explore opinions, identify experiences, and describe perspectives on the acceptability of intravenous (IV) iron to treat anaemia in pregnancy and identify potential barriers and facilitators of introducing IV iron in the Malawian healthcare system.

Methods

We conducted 15 in-depth interviews and two focus group discussions with pregnant women, and seven in-depth interviews with health workers at a community-based health centre in Blantyre and a tertiary hospital in Zomba.

Results

Most women who used IV iron treatment during the second trimester of pregnancy reported feeling better and stronger after receiving the intervention. Women perceived that IV iron treatment worked faster than oral iron tablets and increased their haemoglobin count. However, cultural beliefs that IV iron treatment will cause miscarriage and the perception that study procedures involved Satanism and vampirism practices were barriers to acceptability. Health workers found IV iron treatment easy to administer because it is a single-dose treatment, simultaneously reducing the burden for pregnant women taking daily oral iron tablets. However, health workers expressed concerns about the costs and the need to train health workers before the large-scale implementation and integration of IV iron treatment into Malawi's routine care.

Conclusions

Despite the perceived concerns and challenges experienced in participating in the first IV iron infusion trial in Malawi, participants' reflections suggest that IV iron infusion is acceptable for treating iron-deficiency anaemia in pregnancy. Participant advocate groups can offer a peer-to-peer education approach to sensitize and engage community members on the benefits of treatment and dispel concerns when the country contemplates integrating IV iron infusion for treating anaemia in pregnancy in Malawi.

User Fee Exemption Policy Significantly Improved Adherence to Maternal Health Service Utilization in Bahir Dar City, Northwest Ethiopia: A Comparative Cross-Sectional Study

Background

Increasing free and skilled delivery is a top priority in the global effort to reduce maternal and newborn mortality. Reducing user-fees through exemption policy has contributed to universal health coverage. However, there is scant evidence regarding the effect of exempted maternal services on adherence to utilization in Ethiopia. Thus, this study aimed to assess the effect of fee exemption policy on adherence to maternal health service utilization and its predictors.

Methods

A community-based comparative cross-sectional study was conducted in Bahir Dar City. A two-stage multistage sampling was employed; 497 women participated. Data were collected by face-to-face interview; entered and cleaned using Epi-Data 3.1. SPSS version 25 was used for further analysis. Bivariable and multivariable logistic regression models were computed to assess the association between explanatory and outcome variables. An adjusted odds ratio with a 95% confidence interval was used to interpret the degree of association. The effect of fee exemption policy on adherence to maternal health service utilization was measured by propensity score matching.

Results

The overall adherence to maternal service utilization was 54.2%. Factors associated with adherence to maternal health service utilization were pregnancy complications [AOR: 4.1, 95% CI (2.32, 7.28)], secondary and above education [AOR: 4.6, 95% CI (1.38, 15.08)], early ANC1 booking [AOR: 3.1, 95% CI (1.83, 5.16)], autonomous women [AOR: 2.1, 95% CI (1.02, 4.39)], user fee exemption [AOR: 2.3, 95% CI (1.20, 4.47)] and high parity [AOR: 0.39, 95% CI (0.2, 0.75)]. User fee exemption induced a 22.7% increment in adherence to maternal service utilization (ATET=0.227, t=2.13).

Conclusion

User fee exemption policy significantly improved adherence to maternal health service utilization. Promoting a fee exemption policy through third-party financing can enhance maternal health service utilization adherence in hard-to-reach settings of Ethiopia by targeting mothers with higher pregnancies, no complications, no autonomy, and less education.

Effectiveness of the Gratuité user fee exemption policy on utilization and outcomes of maternal, newborn and child health services in conflict-affected districts of Burkina Faso from 2013 to 2018: a pre-post analysis

BACKGROUND

Evidence on effectiveness of user fee exemption policies targeting maternal, newborn, and child health (MNCH) services is limited for conflict-affected settings. In Burkina Faso, a country that has had its fair share of conflicts, user fee exemption policies have been piloted since 2008 and implemented along with a national government-led user fee reduction policy ('SONU': Soins Obstétricaux et Néonataux d'Urgence). In 2016, the government transitioned the entire country to a user fee exemption policy known as Gratuité. Our study objective was to assess the effect of the policy on the utilization and outcomes of MNCH services in conflict-affected districts of Burkina Faso.

METHODS

We conducted a quasi-experimental study comparing four conflict-affected districts which had the user fee exemption pilot along with SONU before transitioning to Gratuité (comparator) with four other districts with similar characteristics, which had only SONU before transitioning (intervention). A difference-in-difference approach was initiated using data from 42 months before and 30 months after implementation. Specifically, we compared utilization rates for MNCH services, including antenatal care (ANC), facility delivery, postnatal care (PNC) and consultation for malaria. We reported the coefficient, including a 95% confidence interval (CI), p value, and the parallel trends test.

RESULTS

Gratuité led to significant increases in rates of 6th day PNC visits for women (Coeff 0.15; 95% CI 0.01-0.29), new consultations in children < 1 year (Coeff 1.80; 95% CI 1.13-2.47, p < 0.001), new consultations in children 1-4 years (Coeff 0.81; 95% CI 0.50-1.13, p = 0.001), and uncomplicated malaria cases treated in children < 5 years (Coeff 0.59; 95% CI 0.44-0.73, p < 0.001). Other service utilization indicators investigated, including ANC1 and ANC5+ rates, did not show any statistically significant positive upward trend. Also, the rates of facility delivery, 6th hour and 6th week postnatal visits were found to have increased more in intervention areas compared to control areas, but these were not statistically significant.

CONCLUSIONS

Our study shows that, even in conflict-affected areas, the Gratuité policy significantly influences MNCH service utilization. There is a strong case for continued funding of the user fee exemption policy to ensure that gains are not reversed, especially if the conflict ceases to abate.

Spatial disparities in impoverishing effects of out-of-pocket health payments in Malawi

BACKGROUND

Out-of-pocket health payments as a means of financing health services are a cause of concern among households in low and middle-income countries. They prevent households from accessing health care services, can disrupt households' living standards by reducing consumption of other basic needs and push households into poverty. Previous studies have reported geographical variations in impoverishing effects of out-of-pocket health payments. Yet, we know relatively little about spatial effects on impoverishing effects of health payments.

OBJECTIVE

This paper assesses the factors associated with impoverishing effects of health payments and quantifies the role of districts spatial effects on impoverishment in Malawi.

METHODS

The paper uses a cross sectional integrated household survey data collected from April 2016 to April 2017 among 12447 households in Malawi. Impoverishing effect of out-of-pocket health payments was calculated as the difference between poverty head count ratio before and after subtracting health payments from total household consumption expenditures. We assessed the factors associated with impoverishment and quantified the role of spatial effects using a spatial multilevel model.

RESULTS

About 1.6% and 1.2% of the Malawian population were pushed below the national and international poverty line of US$1.90 respectively due health payments. We found significant spatial variations in impoverishment across districts with higher spatial residual effects clustering in central region districts. Higher socio-economic status (AOR=0.34, 95% CI=0.22-0.52) decreased the risk of impoverishment whereas hospitalizations (AOR=3.63, 95% CI 2.54-5.15), chronic illness (AOR=1.56, 95% CI=1.10-1.22), residency in rural area (AOR=2.03, 95% CI=1.07-4.26) increased the risk of impoverishment.

CONCLUSIONS

Our study suggests the need to plan financial protection programs according to district specific needs and target the poor, residents of rural areas and those with chronic illnesses. Policy makers need to pay attention to the importance of spatial and neighborhood effects when designing financial protection programs and policies.

The impact of maternal health insurance coverage and adequate healthcare services utilisation on the risk of under-five mortality in Nigeria: a cross-sectional study

Background

Despite the progress in reducing under-five mortality (U-5 M) in recent years, these deaths remain considerably high in Nigeria. This could be attributed to poor health policies including inequality of health insurance coverage and access to adequate healthcare services utilisations which has remained inimical to achieving sustainable development goals (SDGs). Therefore, this study examined the impact of maternal health insurance coverage and adequate healthcare services utilisation on the risk of U-5 M in Nigeria.

Methods

The data for the study were derived from the 2018 Nigeria Demographic and Health Survey and comprised a weighted sample of 127,545 birth histories of childbearing women. Descriptive and analytical analyses were carried out, including frequency tables and multivariate using Cox proportional regression. The results were presented as hazard ratios (HR) with 95% confidence intervals (CIs). Data were analyzed using Stata software version 15.1.

Results

The results showed that 14.3% of the sampled birth histories of the childbearing women were children who died before age 5. The results further showed that 97.7% of the children were of mothers who have health insurance and over one-half (56.5%) were children whose mothers had adequate healthcare services utilisation. The risk of under-five death was significantly lower among the children of mothers who were covered by health insurance (HR: 0.66, CI: 0.42–1.02) and those whose mothers utilised adequate healthcare services (HR: 0.78, CI: 0.68–0.90). A similar result was observed among children whose mothers reported that distance to the health facility was not a problem (HR: 0.81, CI: 0.72–0.86). Some mothers’ characteristics including educational attainment, wealth quintile and region of residence significantly influenced the risk of U-5 M.

Conclusions

The study established that maternal health insurance coverage and adequate healthcare services utilisation were found to be protective factors against the risk of U-5 M. Also, the revealed low health insurance coverage of mothers calls for more pragmatic policy and intervention programmes through health insurance to achieve SDGs targets of ending preventable deaths of children under 5 years of age and ensuring quality, as well as universal access to maternal and child healthcare services.

Are cesarean deliveries equitable in India: assessment using benefit incidence analysis

BACKGROUND

In the last two decades, cesarean section (CS) deliveries in India have increased by six-fold and created economic hardship for families and households. Although several schemes and policies under the National Health Mission (NHM) have reduced the inequality in the use of maternal care services in India, the distributive effect of public health subsidies on CS deliveries remains unclear. In this context, this paper examines the usage patterns of CS delivery and estimates the share of public health subsidies on CS deliveries among mothers by different background characteristics in India.

DATA

Data from the fourth round of the National Family Health Survey (NFHS-4) was used for the study. Out-of-pocket (OOP) payment for CS delivery was used as a dependent variable and was analyzed by level of care that is, primary (PHC, UHC, other) and secondary (government/municipal, rural hospital). Descriptive statistics, binary logistic regression, benefit incidence analysis, concentration curve and concentration index were used for the analysis.

RESULTS

A strong economic gradient was observed in the utilization of CS delivery from public health facilities. Among mothers using any public health facility, 23% from the richest quintile did not pay for CS delivery compared to 13% from the poorest quintile. The use of the public subsidy among mothers using any type of public health facility for CS delivery was pro-rich in nature; 9% in the poorest quintile, 16.1% in the poorer, 24.5% in the middle, 27.5% among richer and 23% in the richest quintile. The pattern of utilization and distribution of public subsidy was similar across the primary and secondary health facilities but the magnitude varied. The findings from the benefit-incidence analysis are supported by those obtained from the inequality analysis. The concentration index of CS was 0.124 for public health centers and 0.291 for private health centers. The extent of inequality in the use of CS delivery in public health centers was highest in the state of Mizoram (0.436), followed by Assam (0.336), and the lowest in Tamil Nadu (0.060), followed by Kerala (0.066).

CONCLUSION

The utilization of CS services from public health centers in India is pro-rich. Periodically monitoring and evaluating of the cash incentive schemes for CS delivery and generating awareness among the poor would increase the use of CS delivery services in public health centers and reduce the inequality in CS delivery in India.

Perceptions and experiences of intravenous iron treatment for anaemia in pregnancy in Malawi: a formative qualitative study

Background: The study objective was to explore opinions, identify experiences, and describe perspectives on the acceptability of intravenous (IV) iron to treat anaemia in pregnancy and identify potential barriers and facilitators of introducing IV iron in the Malawian healthcare system. Methods: We conducted 15 in-depth interviews and two focus group discussions with pregnant women, and seven in-depth interviews with health workers at a community-based health centre in Blantyre and a tertiary hospital in Zomba. Results: Most women who used IV iron treatment during the second trimester of pregnancy reported feeling better and stronger after receiving the intervention. Women perceived that IV iron treatment worked faster and increased their haemoglobin count. However, cultural beliefs that IV iron treatment will cause miscarriage and the perception that study procedures involved Satanism and vampirism practices were barriers to acceptability. Health workers found IV iron treatment easy to administer because it is a single-dose treatment, simultaneously reducing the burden for pregnant women taking daily oral iron tablets. However, health workers expressed concerns about the costs and the need to train health workers before the large-scale implementation and integration of IV iron treatment into Malawi’s routine care. Conclusions: Despite the perceived concerns and challenges experienced in participating in the first IV iron infusion trial in Malawi, participants’ reflections suggest that IV iron infusion is acceptable for treating iron-deficiency anaemia in pregnancy. Participant advocate groups can offer a peer-to-peer education approach to sensitize and engage community members on the benefits of treatment and dispel concerns when the country contemplates integrating IV iron infusion for treating anaemia in pregnancy in Malawi.

Perspectives of stakeholders of the free maternity services for mothers in western Kenya: lessons for universal health coverage

Background

The strategic aim of universal health coverage (UHC) is to ensure that everyone can use health services they need without risk of financial hardship. Linda Mama (Taking care of the mother) initiative focuses on the most vulnerable women, newborns and infants in offering free health services. Financial risk protection is one element in the package of measures that provides overall social protection, as well as protection against severe financial difficulties in the event of pregnancy, childbirth, neonatal and perinatal health care for mothers and their children.

Purpose

The aim of this study was to find out the extent of awareness, and involvement among managers, service providers and consumers of Linda mama supported services and benefits of the initiative from the perspectives of consumers, providers and managers.

Methods

We carried out cross sectional study in four sub counties in western Kenya: Rachuonyo East, Nyando, Nyakach, and Alego Usonga. We used qualitative techniques to collect data from purposively selected Linda Mama project implementors, managers, service providers and service consumers. We used key informant interview guides to collect data from a total of thirty six managers, nine from each Sub -County and focus group discussion tools to collect data from sixteen groups of service consumers attending either antenatal or post-natal clinics, four from each sub county, selecting two groups from antenatal and two from postnatal clinics in each sub county. Data analysis was based on thematic content analysis.

Findings

Managers and service providers were well aware of the initiative and were involved in it. Participation in Linda Mama, either in providing or using, seemed to be more prominent among managers and service providers. Routine household visits by community health volunteers to sensitize mothers and community engagement was core to the initiative. The managers and providers of services displayed profound awareness of how requiring identification cards and telephone numbers had the potential to undermine equity by excluding those in greater need of care such as under-age pregnant adolescents. Maternity and mother child health services improved as a result of the funds received by health facilities. Linda Mama reimbursements helped to purchase drug and reduced workload in the facility by hiring extra hands.

Conclusion

The initiative seems to have influenced attitudes on health facility delivery through: Partnership among key stakeholders and highlighting the need for enhanced partnership with the communities. It enhanced the capacity of health facilities to deliver high quality comprehensive, essential care package and easing economic burden.

How equitable is health spending on curative services and institutional delivery in Malawi? Evidence from a quasi-longitudinal benefit incidence analysis

Background

Malawi is one of a handful of countries that had resisted the implementation of user fees, showing a commitment to providing free healthcare to its population even before the concept of Universal Health Coverage (UHC) acquired global popularity. Several evaluations have investigated the effects of key policies, such as the essential health package or performance-based financing, in sustaining and expanding access to quality health services in the country. Understanding the distributional impact of health spending over time due to these policies has received limited attention. Our study fills this knowledge gap by assessing the distributional incidence of public and overall health spending between 2004 and 2016.

Methods

We relied on a Benefit Incidence Analysis (BIA) to measure the socioeconomic inequality of public and overall health spending on curative services and institutional delivery across different health facility typologies. We used data from household surveys and National Health Accounts. We used a concentration index (CI) to determine the health benefits accrued by each socioeconomic group.

Results

Socioeconomic inequality in both public and overall health spending substantially decreased over time, with higher inequality observed in overall spending, non-public health facilities, curative health services, and at higher levels of care. Between 2004 and 2016, the inequality in public spending on curative services decreased from a CI of 0.037 (SE 0.013) to a CI of 0.004 (SE 0.011). Whiles, it decreased from a CI of 0.084 (SE 0.014) to a CI of 0.068 (SE 0.015) for overall spending in the same period. For institutional delivery, inequality in public and overall spending decreased between 2004 and 2016 from a CI of 0.032 (SE 0.028) to a CI of -0.057 (SE 0.014) and from a CI of 0.036 (SE 0.022) to a CI of 0.028 (SE 0.018), respectively.

Conclusions

Through its free healthcare policy, Malawi has reduced socioeconomic inequality in health spending over time, but some challenges still need to be addressed to achieve a truly egalitarian health system. Our findings indicate a need to increase public funding for the health sector to ensure access to care and financial protection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01624-5.

Decomposing socio-economic inequality in catastrophic out-of-pocket health expenditures in Malawi

Reducing health inequalities and inequities is one of the key goals that health systems aspire to achieve as it ensures improvement in health outcomes among all population groups. Addressing the factors contributing to inequality in catastrophic health expenditures is important to reducing inequality in the burden of health expenditures. However, there are limited studies to explain the factors contributing to inequalities in catastrophic health expenditures. The study aimed to measure and decompose socio-economic inequality in catastrophic health into its determinants. Data for the analysis come from the fourth integrated household survey. Data for 12447 households in Malawi were collected from April 2016 to April 2017 by the National Statistical Office. The secondary analysis was conducted from June 2021 to October 2021. Catastrophic health expenditure was estimated as a proportion of households whose out-of-pocket health expenditures as a ratio of non-food consumption expenditures exceeds 40% threshold level. We estimated the magnitude of socio-economic inequality using the Erreygers corrected concentration index and used decomposition analysis to assess the contribution of inequality in each determinant of catastrophic health expenditure to the overall socio-economic inequality. The magnitude of the Erreygers corrected concentration index of catastrophic health expenditure (CI = 0.004) is small and positive which indicates that inequality is concentrated among the better-off. Inequality in catastrophic health expenditure is largely due to inequalities in rural residency (127%), socio-economic status (-40%), household size (14%), presence of a child under five years old (10%) and region of the household (10%). The findings indicate that socio-economic inequality in catastrophic health expenditures is concentrated among the better-off in Malawi. The results imply that policies that aim to reduce inequalities in catastrophic health expenditures should simultaneously address urban-rural and income inequalities.

Decomposing socio-economic inequalities in antenatal care utilisation in 12 Southern African Development Community countries

Although many countries are making progress towards achieving the global sustainable development goals, sub-Saharan Africa (SSA) lags behind. SSA bears a relatively higher burden of maternal morbidity and mortality than other regions despite existing cost-effective interventions. This paper assesses antenatal care (ANC) service utilisation among women in the Southern African Development Community (SADC) countries, one of the four SSA regions. Specifically, it assesses socioeconomic inequality in the number of ANC visits, use of no ANC service, between one and three ANC visits and at least four ANC visits, previously recommended by the World Health Organization (WHO). Data come from the most recent Demographic and Health Surveys in twelve SADC countries. Wagstaff's normalised concentration index (CI) was used to assess socioeconomic inequalities. Factors explaining these inequalities were assessed using a standard method and similar variables contained in the DHS data. A positive CI means that the variable of interest is concentrated among wealthier women, while a negative CI signified the opposite. The paper found that wealthier women in the SADC countries are generally more likely to have more ANC visits than their poorer counterparts. Apart from Zambia, the CIs were positive for inequalities in at least 4 ANC visits and negative for between 1 and 3 ANC visits. Women from poorer backgrounds significantly report no ANC visits than wealthier women. Apart from the portion that was not explainable due to limitations in the variables included in the model, critical social determinants of health, including wealth, education and the number of children, explain socioeconomic inequalities in ANC coverage in SADC. A vital policy consideration is not to leave any woman behind. Therefore, addressing access barriers and critical social determinants of ANC inequalities, such as women's education and economic well-being, can potentially redress inequalities in ANC coverage in the SADC region.

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Wealthier women have more antenatal care (ANC) visits than their poorer counterparts.

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Women from poorer backgrounds report no ANC visits more often than wealthier women.

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Wealth and education are key drivers of socioeconomic inequalities in ANC coverage.

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Poorer women are being left behind in accessing maternal health services in Africa.

Alleviating the burden of diabetes with Health Equity Funds: Economic evaluation of the health and financial risk protection benefits in Cambodia

In Cambodia, diabetes caused nearly 3% of the country's mortality in 2016 and became the fourth highest cause of disability in 2017. Providing sufficient financial risk protection from health care expenditures may be part of the solution towards effectively tackling the diabetes burden and motivating individuals to appropriately seek care to effectively manage their condition. In this study, we aim to estimate the distributional health and financial impacts of strategies providing financial coverage for diabetes services through the Health Equity Funds (HEF) in Cambodia. The trajectory of diabetes was represented using a Markov model to estimate the societal costs, health impacts, and individual out-of-pocket expenditures associated with six strategies of HEF coverage over a time horizon of 45 years. Input parameters for the model were compiled from published literature and publicly available household survey data. Strategies covered different combinations of types of diabetes care costs (i.e., diagnostic services, medications, and management of diabetes-related complications). Health impacts were computed as the number of disability-adjusted life-years (DALYs) averted and financial risk protection was analyzed in terms of cases of catastrophic health expenditure (CHE) averted. Model simulations demonstrated that coverage for medications would be cost-effective, accruing health benefits ($27 per DALY averted) and increases in financial risk protection ($2 per case of CHE averted) for the poorest in Cambodia. Women experienced particular gains in health and financial risk protection. Increasing the number of individuals eligible for financial coverage also improved the value of such investments. For HEF coverage, the government would pay between an estimated $28 and $58 per diabetic patient depending on the extent of coverage and services covered. Efforts to increase the availability of services and capacity of primary care facilities to support diabetes care could have far-reaching impacts on the burden of diabetes and contribute to long-term health system strengthening.

Impact of free maternity policies in Kenya: an interrupted time-series analysis

BACKGROUND

User fees have been reported to limit access to services and increase inequities. As a result, Kenya introduced a free maternity policy in all public facilities in 2013. Subsequently in 2017, the policy was revised to the Linda Mama programme to expand access to private sector, expand the benefit package and change its management.

METHODS

An interrupted time-series analysis on facility deliveries, antenatal care (ANC) and postnatal care (PNC) visits data between 2012 and 2019 was used to determine the effect of the two free maternity policies. These data were from 5419 public and 305 private and faith-based facilities across all counties, with data sourced from the health information system. A segmented negative binomial regression with seasonality accounted for, was used to determine the level (immediate) effect and trend (month-on-month) effect of the policies.

RESULTS

The 2013 free-maternity policy led to a 19.6% and 28.9% level increase in normal deliveries and caesarean sections, respectively, in public facilities. There was also a 1.4% trend decrease in caesarean sections in public facilities. A level decrease followed by a trend increase in PNC visits was reported in public facilities. For private and faith-based facilities, there was a level decrease in caesarean sections and ANC visits followed by a trend increase in caeserean sections following the 2013 policy.Furthermore, the 2017 Linda Mama programme showed a level decrease then a trend increase in PNC visits and a 1.1% trend decrease in caesarean sections in public facilities. In private and faith-based facilities, there was a reported level decrease in normal deliveries and caesarean sections and a trend increase in caesarean sections.

CONCLUSION

The free maternity policies show mixed effects in increasing access to maternal health services. Emphasis on other accessibility barriers and service delivery challenges alongside user fee removal policies should be addressed to realise maximum benefits in maternal health utilisation.

[Improving provision of mother-and-child care in Chad at the community level: A quasi-experimental study]

BACKGROUND

Chad is among the countries with the highest maternal and infant mortality rates in the world. An initiative aimed at improving mother-and-child health services was implemented from 2016 to 2019 in three rural health districts in southern Chad, with strong community input, while concomitantly increasing the supply and demand for care. The objective of this study is to evaluate the effects of this program on health service use.

METHODS

Interrupted time-series analyses with a control group was used to measure the effects of the intervention by applying a quasi-experimental approach. Monthly attendance data were collected from the registries of the 18 health centres that participated in the program and 18 centres that did not participate (control group), before (18 months) and after (24 months) the start of implementation.

RESULTS

On average, there were 10.98 (95% CI: 6.57-15.39, P<0.001) additional paediatric visits and 0.68 additional deliveries (95% CI: 0.42-0.95, P<0.001) each month in the participation group compared to the control group. Community involvement decisively contributed to the change.

CONCLUSION

During the 24 months of implementation, the initiative significantly increased the use of essential mother-and-child health services in Chad. This study highlights the benefits of a strong partnership with communities trained and involved in health system activities, with the objective of achieving universal health coverage.

Health Insurance Status of Pregnant Women and the Likelihood of Receipt of Antenatal Screening for HIV in Sub-Saharan Africa

BACKGROUND

We investigated if initiating preventive care against HIV vertical transmission by antenatal HIV screening is independent of the patients' source of financial reimbursement for the care received in sub-Saharan Africa (SSA).

METHODS

Using information from the WHO's Global Health Expenditure Database and the Demographic Health Surveys Database for 27 sub-Saharan countries, we used Spearman's correlation and adjusted survey logistic regression to determine the potential relationship between enrollment in health insurance and the likelihood that expectant mothers would be offered antenatal HIV screening.

RESULTS

We found that expectant mothers covered by health insurance were more than twice as likely to be offered antenatal screening for HIV compared to the uninsured. The likelihood differed by the type of insurance plan the expectant mother carried.

DISCUSSION

Health insurance is more of a financial tool that this study finds to be necessary to boost the uptake of preventive and therapeutic HIV care in SSA.

CONCLUSION

The ensuing disparity in receiving proper care could hinder the goals of 90-90-90 and the forthcoming 95-95-95 plan in SSA.

Examining the incidence of catastrophic health expenditures and its determinants using multilevel logistic regression in Malawi

BACKGROUND

Despite a free access to public health services policy in most sub-Saharan African countries, households still contribute to total health expenditures through out-of-pocket expenditures. This reliance on out-of-pocket expenditures places households at a risk of catastrophic health expenditures and impoverishment. This study examined the incidence of catastrophic health expenditures, impoverishing effects of out-of-pocket expenditures on households and factors associated with catastrophic expenditures in Malawi.

METHODS

We conducted a secondary analysis of the most recent nationally representative integrated household survey conducted by the National Statistical Office between April 2016 to 2017 in Malawi with a sample size of 12447 households. Catastrophic health expenditures were estimated based on household annual nonfood expenditures and total household annual expenditures. We estimated incidence of catastrophic health expenditures as the proportion of households whose out-of-pocket expenditures exceed 40% threshold level of non-food expenditures and 10% of total annual expenditures. Impoverishing effect of out-of-pocket health expenditures on households was estimated as the difference between poverty head count before and after accounting for household health payments. We used a multilevel binary logistic regression model to assess factors associated with catastrophic health expenditures.

RESULTS

A total of 167 households (1.37%) incurred catastrophic health expenditures. These households on average spend over 52% of household nonfood expenditures on health care. 1.6% of Malawians are impoverished due to out-of-pocket health expenditures. Visiting a religious health facility (AOR = 2.27,95% CI:1.24-4.15), hospitalization (AOR = 6.03,95% CI:4.08-8.90), larger household size (AOR = 1.20,95% CI:1.24-1.34), higher socioeconomic status (AOR = 2.94,95% CI:1.39-6.19), living in central region (AOR = 3.54,95% CI:1.79-6.97) and rural areas (AOR = 5.13,95% CI:2.14-12.29) increased the odds of incurring catastrophic expenditures.

CONCLUSION

The risk of catastrophic health expenditures and impoverishment persists in Malawi. This calls for government to improve the challenges faced by the free public health services and design better prepayment mechanisms to protect more vulnerable groups of the population from the burden of out-of-pocket payments.

Developing Malawi's Universal Health Coverage Index

The inclusion of Universal Health Coverage (UHC) in the Sustainable Development Goals (target 3.8) cemented its position as a key global health priority and highlighted the need to measure it, and to track progress over time. In this study, we aimed to develop a summary measure of UHC for Malawi which will act as a baseline for tracking UHC index between 2020 and 2030. We developed a summary index for UHC by computing the geometric mean of indicators for the two dimensions of UHC; service coverage (SC) and financial risk protection (FRP). The indicators included for both the SC and FRP were based on the Government of Malawi's essential health package (EHP) and data availability. The SC indicator was computed as the geometric mean of preventive and treatment indicators, whereas the FRP indicator was computed as a geometric mean of the incidence of catastrophic healthcare expenditure, and the impoverishing effect of healthcare payments indicators. Data were obtained from various sources including the 2015/2016 Malawi Demographic and Health Survey (MDHS); the 2016/2017 fourth integrated household survey (IHS4); 2018/2019 Malawi Harmonized Health Facility Assessment (HHFA); the MoH HIV and TB data, and the WHO. We also conducted various combinations of input indicators and weights as part of sensitivity analysis to validate the results. The overall summary measure of UHC index was 69.68% after adjusting for inequality and unadjusted measure was 75.03%. As regards the two UHC components, the inequality adjusted summary indicator for SC was estimated to be 51.59% and unadjusted measure was 57.77%, whereas the inequality adjusted summary indicator for FRP was 94.10% and unweighted 97.45%. Overall, with the UHC index of 69.68%, Malawi is doing relatively well in comparison to other low income countries, however, significant gaps and inequalities still exist in Malawi's quest to achieve UHC especially in the SC indicators. It is imperative that targeted health financing and other health sector reforms are made to achieve this goal. Such reforms should be focused on both SC and FRP rather than on only either, of the dimensions of UHC.

Effect of Implementing a Free Delivery Service Policy on Women's Utilization of Facility-Based Delivery in Central Ethiopia: An Interrupted Time Series Analysis

Background

Access to and utilization of facility delivery services is low in Ethiopia. The government of Ethiopia introduced a free delivery service policy in all public health facilities in 2013 to encourage mothers to deliver in health facilities. Examining the effect of this intervention on the utilization of delivery services is very important.

Objective

In this study, we assessed the effect of provisions of free maternity care services on facility-based delivery service utilization in central Ethiopia.

Methods

Data on 108 time points were collected on facility-based delivery service utilization (72 pre- and 36 postintervention) for a period of nine years from July 2007 to June 2016. Routine monthly data were extracted from the District Health Information System and verified using data from the delivery ward logbooks across the study facilities. An interrupted time-series analysis was conducted to assess the effect of the intervention.

Results

The implementation of the free delivery services policy has significantly increased facility deliveries. During the study period, there was a statistically significant increase in the number of facility-based deliveries after the 24^th and 36^th months of intervention (p < 0.05). Program effects on the use of public facilities for deliveries were persisted over a longer exposure period.

Conclusion

The findings suggested that the provision of free delivery services at public health facilities increased facility delivery use. The improved utilization of facility delivery services was more marked over a longer exposure period. Policy-makers may consider mobilizing the communities aware of the program at its instigation.

Pro-equity legislation, health policy and utilisation of sexual and reproductive health services by vulnerable populations in sub-Saharan Africa: a systematic review

Twenty-five years ago, the International Conference on Population and Development highlighted the need to address sexual and reproductive health (SRH) rights on a global scale. The sub-Saharan Africa region continues to have the highest levels of maternal mortality and HIV, primarily affecting the most vulnerable populations. Recognising the critical role of policy in understanding population health, we conducted a systematic review of original primary research which examined the relationships between equity-focused legislation and policy and the utilisation of SRH services by vulnerable populations in sub-Saharan Africa. We searched nine bibliographic databases for relevant articles published between 1994 and 2019. Thirty-two studies, conducted in 14 sub-Saharan African countries, met the inclusion criteria. They focused on maternal health service utilisation, either through specific fee reduction/removal policies, or through healthcare reforms and insurance schemes to increase SRH service utilisation. Findings across most of the studies showed that health-related legislation and policy promoted an increase in service utilisation, over time, especially for antenatal care, skilled birth attendance and facility-based delivery. However, social health inequalities persisted among subgroups of women. Neither the reviewed studies nor the policies specifically addressed youth, people living with HIV and people with disabilities. In the era of the sustainable development goals, addressing health inequities in the context of social determinants of health becomes unavoidable. Systematic and rigorous quantitative and qualitative research, including longitudinal policy evaluation, is required to understand the complex relationships between policy addressing upstream social determinants of health and health service utilisation.

Determinants of healthcare seeking and out-of-pocket expenditures in a "free" healthcare system: evidence from rural Malawi

BACKGROUND

Monitoring financial protection is a key component in achieving Universal Health Coverage, even for health systems that grant their citizens access to care free-of-charge. Our study investigated out-of-pocket expenditure (OOPE) on curative healthcare services and their determinants in rural Malawi, a country that has consistently aimed at providing free healthcare services.

METHODS

Our study used data from two consecutive rounds of a household survey conducted in 2012 and 2013 among 1639 households in three districts in rural Malawi. Given our explicit focus on OOPE for curative healthcare services, we relied on a Heckman selection model to account for the fact that relevant OOPE could only be observed for those who had sought care in the first place.

RESULTS

Our sample included a total of 2740 illness episodes. Among the 1884 (68.75%) that had made use of curative healthcare services, 494 (26.22%) had incurred a positive healthcare expenditure, whose mean amounted to 678.45 MWK (equivalent to 2.72 USD). Our analysis revealed a significant positive association between the magnitude of OOPE and age 15-39 years (p = 0.022), household head (p = 0.037), suffering from a chronic illness (p = 0.019), illness duration (p = 0.014), hospitalization (p = 0.002), number of accompanying persons (p = 0.019), wealth quartiles (p₂ = 0.018; p₃ = 0.001; p₄ = 0.002), and urban residency (p = 0.001).

CONCLUSION

Our findings indicate that a formal policy commitment to providing free healthcare services is not sufficient to guarantee widespread financial protection and that additional measures are needed to protect particularly vulnerable population groups.

Determinants of antenatal care utilisation in sub-Saharan Africa: a systematic review

OBJECTIVES

To identify the determinants of antenatal care (ANC) utilisation in sub-Saharan Africa.

DESIGN

Systematic review.

DATA SOURCES

Databases searched were PubMed, OVID, EMBASE, CINAHL and Web of Science.

ELIGIBILITY CRITERIA

Primary studies reporting on determinants of ANC utilisation following multivariate analysis, conducted in sub-Saharan Africa and published in English language between 2008 and 2018.

DATA EXTRACTION AND SYNTHESIS

A data extraction form was used to extract the following information: name of first author, year of publication, study location, study design, study subjects, sample size and determinants. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist for reporting a systematic review or meta-analysis protocol was used to guide the screening and eligibility of the studies. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to assess the quality of the studies while the Andersen framework was used to report findings.

RESULTS

74 studies that met the inclusion criteria were fully assessed. Most studies identified socioeconomic status, urban residence, older/increasing age, low parity, being educated and having an educated partner, being employed, being married and Christian religion as predictors of ANC attendance and timeliness. Awareness of danger signs, timing and adequate number of antenatal visits, exposure to mass media and good attitude towards ANC utilisation made attendance and initiation of ANC in first trimester more likely. Having an unplanned pregnancy, previous pregnancy complications, poor autonomy, lack of husband's support, increased distance to health facility, not having health insurance and high cost of services negatively impacted the overall uptake, timing and frequency of antenatal visits.

CONCLUSION

A variety of predisposing, enabling and need factors affect ANC utilisation in sub-Saharan Africa. Intersectoral collaboration to promote female education and empowerment, improve geographical access and strengthened implementation of ANC policies with active community participation are recommended.

The impact and cost-effectiveness of user fee exemption by contracting out essential health package services in Malawi

Objectives

To examine the impact and cost-effectiveness of user fee exemption by contracting out essential health package services to Christian Health Association of Malawi (CHAM) facilities through service-level agreements (SLAs) to inform policy-making in Malawi.

Methods

The analysis was conducted from the government perspective. Financial and service utilisation data were collected for January 2015 through December 2016. The impact of SLAs on utilisation of maternal and child health (MCH) services was examined using propensity score matching and random-effects models. Subsequently, the improved services were converted to quality-adjusted life years (QALYs) gained, using the Lives Saved Tool (LiST), and incremental cost-effectiveness ratios (ICERs) were generated.

Findings

Over the 2 years, a total of $1.5 million was disbursed to CHAM facilities through SLAs, equivalent to $1.24 per capita. SLAs were associated with a 13.8%, 13.1%, 19.2% and 9.6% increase in coverage of antenatal visits, postnatal visits, delivery by skilled birth attendants and BCG vaccinations, respectively. This was translated into 434 lives saved (95% CI 355 to 512) or 11 161 QALYs gained (95% CI 9125 to 13 174). The ICER of SLAs was estimated at $134.7/QALYs gained (95% CI $114.1 to $164.7).

Conclusions

The cost per QALY gained for SLAs was estimated at $134.7, representing 0.37 of Malawi’s per capita gross domestic product ($363). Thus, MCH services provided with Malawi’s SLAs proved cost-effective. Future refinements of SLAs could introduce pay for performance, revising the price list, streamlining the reporting system and strengthening CHAM facilities’ financial and monitoring management capacity.

User fee exemption and maternal health care utilisation at mission health facilities in Malawi: An application of disequilibrium theory of demand and supply

The literature on health care utilisation has focussed on the interaction of supply and demand factors in determining utilisation. At the aggregate level, studies have modelled the simultaneity of demand and supply, and different methods have been used. This study proposes an alternative framework for modelling utilisation, which yet separates demand and supply factors, the disequilibrium theory of demand and supply. This theory is useful in modelling data that reflect that not all health care demand is met by health care providers and not all health care supply is taken by consumers. Such disequilibrium arises due to rigid prices and quantity rationing. We use the theory to model maternal health care utilisation and user fee exemption at mission health care facilities in Malawi. The study uses switching regression methods and data from the Malawi Health Management Information System. Results show that user fee exemption is associated with increased utilisation of maternal health care. Demand and supply regime classification shows that many of the health facilities met much of the demand, whereas the rest only provided as much maternal care as their maximum capacity. In the latter case, intended maternal health care utilisation targets may not have been met.

The availability, prices and affordability of essential medicines in Malawi: A cross-sectional study

INTRODUCTION

The Malawian government recently introduced cost-covering consultation fees for self-referral patients in tertiary public hospitals. Previously, patients received medicines free of charge in government-owned health facilities, but must pay elsewhere. Before the government implements a payment policy in other areas of health care, it is important to investigate the prices, affordability and availability of essential medicines in Malawi.

METHODS

Data on availability and prices of 50 essential medicines were collected in 44 health facilities in two major cities and two districts. These included 12 public facilities, 11 facilities of the Christian Health Association of Malawi (CHAM), nine retail pharmacies, eight wholesalers and four private clinics/hospitals. Price, availability and affordability were assessed based on the methodology developed by the World Health Organization and Health Action International, which compares local prices to international reference prices.

RESULTS AND DISCUSSION

The overall availability of medicines was 48.5% in public facilities, 71.1% in retail pharmacies, 62.9% in CHAM facilities and 57.5% in private clinics. The availability of essential medicines varied from 0% for ethosuximide to 100% for amoxicillin and cotrimoxazole tablets. Antibiotic formulations for adults were widely available, in contrast to the low availability of pediatric formulations. Several medicines for non-communicable diseases like sodium valproate, phenytoin, paraldehyde, captopril and simvastatin showed poor availability and affordability. The overall median price ratio compared to the international reference price was 1.11 for wholesalers, 2.54 in CHAM facilities, 2.70 in retail pharmacies, and 4.01 in private clinics, which is low compared to other countries. But nevertheless, for 18 out of 32 medicines assessed, the cost of one course exceeded the statutory minimum daily wage, making them unaffordable to a majority of the population. Therefore, continued provision of free public health care is still of critical importance for the foreseeable future until other financing mechanisms have been explored.

Removal of user fees and system strengthening improves access to maternity care, reducing neonatal mortality in a district hospital in Lesotho

Objective

Lesotho has one of the highest maternal mortality rates in the world. While at primary health care (PHC) level maternity care is free, at hospital level co‐payments are required from patients. We describe service utilisation and delivery outcomes before and after removal of user fees and quality of delivery care, and associated costs, at St Joseph's Hospital (SJH) in Roma, Lesotho.

Methods

We compared utilisation of delivery services, stillbirths and maternal and neonatal mortality for the periods before (1 July 2012 to 31 December 2013) and after (1 January 2014 to 30 June 2015) user fee removal through a retrospective chart review and estimated additional costs attributed to user fee removal from provider (hospital) and patient perspectives.

Results

Of 4715 deliveries 3855 were at SJH and 860 at PHC centres. Of women delivering at SJH 684 (18.5%) were ≤19 years and 894 (23.6%) were HIV positive. After user fee removal hospital deliveries increased by 49% — from 1547 to 2308 — and neonatal mortality decreased from 4.8 to 1.3 per 1000 live births (P = 0.033). Extrapolating costs to the entire country, 1 USD per capita per year would allow user fee removal at hospital level, the provision of free transport to/from and accommodation at hospital.

Conclusion

Removing user fees for hospital delivery care in Lesotho is feasible and affordable, and has the potential to improve maternal and neonatal outcomes by removing financial barriers to skilled birth attendants and increasing coverage of institutional deliveries.

How the introduction of a human resources information system helped the Democratic Republic of Congo to mobilise domestic resources for an improved health workforce

The Democratic Republic of Congo has flagged health workforce management and compensation as issues requiring attention, including the problem of ghost workers (individuals on payroll who do not exist and/or show up at work). Recognising the need for reliable health workforce information, the government has worked to implement iHRIS, an open source human resources information system that facilitates health workforce management. In Kasaï Central and Kasaï Provinces, health workers brought relevant documentation to data collection points, where trained teams interviewed them and entered contact information, identification, photo, current job, and employment and education history into iHRIS on laptops. After uploading the data, the Ministry of Public Health used the database of over 11 500 verified health worker records to analyse health worker characteristics, density, compensation, and payroll. Both provinces had less than one physician per 10 000 population and a higher urban versus rural health worker density. Most iHRIS-registered health workers (57% in Kasaï Central and 73% in Kasaï) reported receiving no regular government pay of any kind (salaries or risk allowances). Payroll analysis showed that 27% of the health workers listed as salary recipients in the electronic payroll system were ghost workers, as were 42% of risk allowance recipients. As a result, the Ministries of Public Health, Public Service, and Finance reallocated funds away from ghost workers to cover salaries (n = 781) and risk allowances (n = 2613) for thousands of health workers who were previously under- or uncompensated due to lack of funds. The reallocation prioritised previously under- or uncompensated mid-level health workers, with 49% of those receiving salaries and 68% of those receiving risk allowances representing cadres such as nurses, laboratory technicians, and midwifery cadres. Assembling accurate health worker records can help governments understand health workforce characteristics and use data to direct scarce domestic resources to where they are most needed.

Has the free maternal health policy eliminated out of pocket payments for maternal health services? Views of women, health providers and insurance managers in Northern Ghana

INTRODUCTION

The free maternal health policy was implemented in Ghana in 2008 under the National Health Insurance Scheme (NHIS). The policy sought to eliminate out of pocket (OOP) payments and enhance the utilisation of maternal health services. It is unclear whether the policy had altered OOP payments for services. The study explored views on costs and actual OOP payments during pregnancy. The source of funding for payments was also explored.

METHODS

A convergent parallel mixed methods design, involving quantitative and qualitative data collection approaches. The study was set in the Kassena-Nankana municipality, a rural area in Ghana. Women (n = 406) who utilised services during pregnancy were surveyed. Also, 10 focus groups discussions (FGDs) were held with women who used services during pregnancy as well as 28 in-depth interviews (IDIs) with midwives/nurses (n = 25) and insurance managers/directors (n = 3). The survey was analysed using descriptive statistics, focussing on costs from the women's perspective. Qualitative data were audio recorded, transcribed and translated verbatim into English where necessary. The transcripts were read and coded into themes and sub-themes.

RESULTS

The NHIS did not cover all expenses in relation to maternal health services. The overall mean for OOP cost during pregnancy was GH¢17.50 (US$8.60). Both FGDs and IDIs showed that women especially paid for drugs and ultrasound scan services. Sixty-five percent of the women used savings, whilst twenty-two percent sold assets to meet the OOP cost. Some women were unable to afford payments due to poverty and had to forgo treatment. Participants called for payments to be eliminated and for the NHIS to absorb the cost of emergency referrals. All participants admitted the benefits of the policy.

CONCLUSION

Women needed to make payments despite the policy. Measures should be put in place to eliminate payments to enable all women to receive services and promote universal health coverage.

The impact of free healthcare on women's capability: A qualitative study in rural Burkina Faso

In March 2006, the government of Burkina Faso implemented an 80% subsidy for emergency obstetric and neonatal care (EmONC). To complement this subsidy, an NGO decided to cover the remaining 20% in two districts of the country, making EmONC completely free for women there. In addition, the NGO instituted fee exemptions for children under five years of age in those two districts. We conducted a qualitative study in 2011 to examine the impact of these free healthcare interventions on women's capability. We conducted semi-structured interviews with 40 women, 16 members of health centre management committees, and eight healthcare workers in three health districts, as well as a documentary analysis. Results showed free healthcare helped reinforce women's capability to make health decisions by eliminating the need for them to negotiate access to household resources, which in turn helped shorten delays in health services use. Other effects were also observed, such as increased self-esteem among the women and greater respect within their marital relationship. However, cultural barriers remained, limiting women's capability to achieve certain things they valued, such as contraception. In conclusion, this study's results illustrate the transformative effect that eliminating fees for obstetric care can have on women's capability to make health decisions and their social position. Furthermore, if women's capability is to be strengthened, the results impel us to go beyond health and to organize social and economic policies to reinforce their positions in other spheres of social life.

Conditional Cash Transfers Improve Retention in PMTCT Services by Mitigating the Negative Effect of Not Having Money to Come to the Clinic

OBJECTIVE

To elucidate the mechanisms by which a cash incentive intervention increases retention in prevention of mother-to-child transmission services.

METHODS

We used data from a randomized controlled trial in Kinshasa, Democratic Republic of Congo. Perceptual factors associated with loss to follow-up (LTFU) through 6 weeks postpartum were first identified. Then, binomial models were used to assess interactions between LTFU and identified factors, and the cash incentive intervention.

RESULTS

Participants were less likely to be LTFU if they perceived HIV as a "very serious" health problem for their baby vs. not [risk difference (RD), -0.13; 95% confidence interval (CI): -0.30 to 0.04], if they believed it would be "very likely" to pass HIV to their baby if they did not take any HIV drug vs. not (RD, -0.15; 95% CI: -0.32 to 0.02), and if they anticipated that not having money would make it difficult for them to come to the clinic vs. not (RD, 0.12; 95% CI: -0.07 to 0.30). The effect of each of the 3 factors on LTFU was antagonistic to that of receiving the cash incentive intervention. The excess risk due to interaction between the cash incentive intervention and the anticipated difficulty of "not having money" to come to the clinic was exactly equal to the effect of removing this perceived barrier (excess risk due to interaction, -0.12; 95% CI: -0.35 to 0.10).

CONCLUSIONS

Our analyses show that cash transfers improve retention in prevention of mother-to-child transmission services mainly by mitigating the negative effect of not having money to come to the clinic.