Applied Health Sciences (Department)
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Item Start-stop funding, its causes and consequences : a case study of the delivery exemptions policy in Ghana(Wiley Interscience, 2007-01-22) Witter, Sophie; Adjei, SamThis article looks at the issue of sustaining funding for a public programme through the case study of the delivery exemptions policy in Ghana. The Government of Ghana introduced the policy of exempting users from delivery fees in September 2003 in the four most deprived regions of the country, and in April 2005 it was extended to the remaining six regions in Ghana. The aim of the policy of free delivery care was to reduce financial barriers to using maternity services. Using materials from key informant interviews at national and local levels in 2005, the article examines how the policy has been implemented and what the main constraints have been, as perceived by different actors in the health system. The interviews show that despite being a high-profile public policy and achieving positive results, the delivery exemptions policy quickly ran into implementation problems caused by inadequate funding. They suggest that facility and district managers bear the brunt of the damage that is caused when benefits that have been promised to the public cannot be delivered. There can be knock-on effects on other public programmes too. Despite these problems, start-stop funding and under-funding of public programmes is more the norm than the exception. Some of the factors causing erratic funding—such as party politics and intersectoral haggling over resources—are unavoidable, but others, such as communication and management failures can and should be addressed.Item Effect of delivery care user fee exemption policy on institutional maternal deaths in the Central and Volta regions of Ghana(Ghana Medical Association, 2007-09) Bosu, W.K.; Bell, Jacqueline S.; Armar-Klemesu, Margaret; Ansong-Tornui, Janet; University of Aberdeen, School of Medicine & Dentistry, Division of Applied Health SciencesBackground: To improve access to skilled attendance at delivery and thereby reduce maternal mortality, the Government of Ghana introduced a policy exempting all women attending health facilities from paying delivery care fees. Objective: To examine the effect of the exemption policy on delivery-related maternal mortality. Methods: Maternal deaths in 9 and 12 hospitals in the Central Region (CR) and the Volta Region (VR) respectively were analysed. The study covered a period of 11 and 12 months before and after the introduction of the policy between 2004 and 2006. Maternal deaths were identified by screening registers and clinical notes of all deaths in women aged 15-49 years in all units of the hospitals. These deaths were further screened for those related to delivery. The total births in the study period were also obtained in order to calculate maternal mortality ratios (MMR). Results: A total of 1220 (78.8%) clinical notes of 1549 registered female deaths were retrieved. A total of 334 (21.6%) maternal deaths were identified. The delivery-related MMR decreased from 445 to 381 per 100,000 total births in the CR and from 648 to 391 per 100,000 total births in the VR following the implementation of the policy. The changes in the 2 regions were not statistically significant (p=0.458) and (p=0.052) respectively. No significant changes in mean age of delivery-related deaths, duration of admission and causes of deaths before and after the policy in both regions. Conclusion: The delivery-related institutional maternal mortality did not appear to have been significantly affected after about one year of implementation of the policy. In late 2003, the Government of Ghana introduced a policy exempting women in the four poorest regions of the country (the three northern regions and the Central Region) attending public and private health facilities from paying user fees for delivery care. An amount of about USD 2 million was voted for this purpose. The ‘fee-free’ delivery policy aimed to improve levels of skilled attendance at birth and thereby reduce maternal morbidity and mortality. In 2005, the policy was extended to the remaining six regions of the country1. As part of a multi-component study evaluating this policy, we investigated the effect of the policy on institutional maternal mortality in two regions. The objectives of the study were to measure any effect of the intervention on hospital maternal mortality ratios (MMRs) for all maternal deaths, and focus, in particular, on delivery-related deaths, as these should be most influenced by the policy. Reported figures from the Central Region demonstrate a significant reduction in total institutional MMR from 2001 through to 20042,3. We anticipated, this trend could reverse if increasing numbers of complicated cases referred from lower level facilities or reported directly to the district hospitals in response to the free delivery care policy. We also analysed the change in the distribution of causes of the maternal death over the study period.