Changes in maternal health care provision & funding
There is a compelling case to invest in women and girls, including health financing to achieve better maternal health outcomes. Here Dr Allyala K Nandakumar (USAID) and Dr Laurel Hatt (Abt Associates), co-authors on The Lancet paper by Marjorie Koblinsky et al, highlight strategies to sustainably finance maternal health care in the future. We will explore approaches to financing including; persuading governments to finance maternal health; maintain donor funding for the most vulnerable; and using strategic purchasing and performance-based incentives.
There is consensus around the investment case for investing in the health and education of women1-4, with one estimate showing that investments in reducing maternal and child mortality would produce “nine times the economic and social benefit by 20354.” However, governments need to help with this investment. Financial barriers hinder access to maternal health services for poor and vulnerable women in low- and middle-income countries5-7. Maternal health expenditure can be catastrophic, tipping families into poverty8. Reducing the burden of out-of-pocket spending through risk pooling mechanisms is positively correlated with the use of maternal health services, even as the effects on quality-of-care and health outcomes are inconclusive9-11.
How can sustainable financing for maternal health be ensured?
A starting point is estimating the resources needed to achieve better maternal health results and comparing these with resources available. Useful costing and planning tools include the System of Health Accounts 2011; the Spectrum Suite of Models; Core Plus and most recently the OneHealth Tool. A recent study estimated that between 2013-2035, an additional US$72.1 billion will be needed globally to cover an essential package of maternal and newborn health services.4
To mobilize needed resources, a three-pronged approach is necessary to ensure sustainable financing:
- Effectively employ strategic purchasing and performance-based incentives
- Capture expanded domestic fiscal space for maternal health
- Deploy coordinated, targeted donor assistance for vulnerable populations and settings
1. Effectively employ strategic purchasing and performance-based incentives
To substantially improve maternal health countries should ensure the optimal allocation and efficient use of resources. This can be done through “strategic purchasing” of maternal care: proactively identifying which models of care and interventions to invest in; determining how they should be purchased; for whom they should be purchased; and selecting which health care providers to purchase services from – those who can provide the highest quality of care most efficiently, whether public or private12,13. Not only can this active purchasing approach promote efficiency, but also - if designed well - the mechanisms for paying providers can incentivize improvements in the quality of care14. Reviews of the effects of financial incentive programs, including performance- or results-based financing (RBF) and vouchers, on improving the quality and quantity of maternal health service provision suggest these programs can be successful, especially when users have a choice among providers15. It is important to carefully design these schemes and rigorously monitor them to avoid unintended consequences.
Private-sector providers form a significant part of health systems in many countries, and are currently responsible for one in every five deliveries across 57 low- and middle-income countries16. Approaches such as contracting and possibly social franchising can leverage the power of the private health sector to deliver maternal health services efficiently and effectively17. Contracts set clear expectations for providers and tie payments to achievement of predefined objectives18.
2. Capture expanded domestic fiscal space for maternal health
Between 1995 and 2011, donor spending declined among countries that transitioned from low- to lower-middle-income status. However, governments in those countries did not always step in to fill the gap. This led to an increase in out-of-pocket spending on health19. Similarly, every percentage point increase in economic growth in low-income countries is associated with only half a percentage point growth in government spending on health20. Although low- and middle-income countries have some of the fastest growing economies, strong advocacy is needed to ensure that this growth is captured by the health sector and appropriately allocated to maternal health services. Advocates should campaign for improving countries’ tax policy and tax administration; promote opportunities to mobilize new resources for maternal health (for example, through sales taxes on alcohol and tobacco, tourist taxes, and redirecting fossil fuel subsidies), and ensure that maternal health services are covered by insurance or other subsidized financing programmes.
3. Deploy coordinated, targeted donor assistance for vulnerable populations and settings
Some countries are extremely poor or fragile. Continued donor support for maternal health interventions is most critical where need cannot be met via domestic resources. This is especially true for poor and vulnerable women left out of good quality maternal care systems – for instance in post-conflict settings. There is a proliferation of new initiatives for Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH)21. The Global Financing Facility (GFF), which you will hear more about in the next step, was launched in 2015 to improve coordination, and better target donor and domestic funding for women’s, children’s and adolescents’ health. Still, some development players remain sceptical, citing concerns that the GFF will further fragment the global system and undermine the position of UN agencies22. Moreover, it is unclear whether and how such mechanisms will reach the super-vulnerable within countries.
To ensure that women worldwide have sustainable access to high quality maternal health services, advocates must address the system-wide health financing challenges that limit such access. This means 1) using financial incentives to promote efficient, high-quality service provision; 2) generating adequate domestic resources for health; and 3) mobilizing donor funds for the poorest and most vulnerable women.
© The London School of Hygiene & Tropical Medicine