Fee exemption for caesarean section in Morocco

Archives of Public Health, Volume 70, No. 1, Year 2012

Interprétation

Financial barriers are an important obstacle for access to emergency obstetric care and a contributing factor to too slow a reduction in the level of maternal mortality. In Morocco, in 2009, a fee exemption policy for delivery and caesarean section was implemented in public maternity hospitals. As in most countries where a fee exemption policy has been implemented, fee exemption is considered synonym to free care. However, other direct costs may subsist. The objective of this study was to get an estimate of the actual cost of caesarean sections from the patients’ perspective. This study was carried out in April 2010 in the three public hospitals in Fez. We carried out semi-structured interviews among a sample of 100 women who gave birth by caesarian section in the public hospitals in Fez. The results showed that households paid between US$169 (95% Confidence Interval (CI): 153, 185) at the provincial and regional hospitals, and US$291 (95% CI: 224-359) at the university hospital (UH) where the fee exemption was not applied. The direct cost of a caesarean was mainly influenced by the price of the drugs the families bought, the invoice paid at UH, and the transport. Finally, although the fee exemption policy for caesareans has probably reduced the total cost for households who did not have access to a poverty card, it has not led to ‘truly’ free caesarean deliveries. © 2012 Bennis and De Brouwere. The principal investigator (PI) selected the three public referral hospitals in Fez district, Morocco, where he worked. These hospitals serve the city of Fez and the neighboring provinces (Taounat, Moulay Yacoub, Sefrou, Boulmane), a population of 1.7 million inhabitants (5.4% of the total Moroccan population) [9]. Two of the three hospitals, the provincial hospital (PH) and the regional hospital (RH), fall under the SEGMA system (governmental service managed autonomously) and the direct authority of the Ministry of Health (MOH). The third hospital, the university hospital (UH), is managed as an autonomous public institution. In 2009, the two SEGMA hospitals carried out 7952 vaginal deliveries and 1247 caesarean sections, while the UH carried out 4137 vaginal deliveries and 1002 caesareans. Besides these three, there are a number of private hospitals but the average cost of a caesarean in the private sector is higher than US$1000, which makes it inaccessible for the poor; moreover the decision to provide fee exemption for caesarean deliveries does not apply to the private sector. Normal (vaginal) deliveries have been free in the public small maternities since decades and are free since 2009 in public hospitals. Before the fee exemption policy, normal delivery had to be paid at a flat fee of $64 in public hospitals, except if the woman could bring the evidence of her indigence (thanks to a poverty card obtained from the local authority, a sometimes long and difficult process) or if she was covered by a health insurance (a small minority of the population). For a caesarean section, women had to pay a lump sum of $283 [10]. The additional costs for a vaginal delivery, due for instance to prescribed drugs, have not been investigated although these costs, in the experience of the investigators, were kept low. Tariffs have been abolished by the fee exemption policy. Initially, the MOH distributed delivery and caesarean kits in which the essential medicines and consumables were packed to all the public facilities. Later, in 2010, public hospitals got an additional budget to order the required essential drugs and consumables for deliveries and C-sections. The list of drugs is however limited to the WHO essential ones and usually are generic medicines. The information about household expenditure was collected between 1st and 30th April 2010, as part of the practical training of the PI, from a sample of 100 women who gave birth by caesarean section in one of the three hospitals: 68 in the RH (all women delivered by caesarean section in April 2010), 16 in the PH (interviews taken from all the women delivered by caesarean in the week of 16th to 23rd April 2010) and 16 in the UH (interviews of all the women delivered by caesarean from 19th to 30th April 2010). The women were interviewed together with their family at the moment they left the hospital (26 patients, 56 husbands and 18 accompanying persons (carers other than the husband)). The information about the direct cost of the caesarean section was collected through a questionnaire with a mix of open and closed questions. The first part, designed for the women and/or their carers immediately after the delivery consisted of face-to-face interviews. It was carried out inside the hospital and aimed at gathering information about the pregnancy and about the degree of knowledge about the fee exemption system for caesareans; and at putting the interviewed person (the husband in most cases) at ease. During this first interview the investigator also asked the consent of the interviewee to continue the interview at a later stage – once the patient had left the hospital – through a telephone survey. This latter part of the interview primarily focused on drug costs after leaving the hospital and the cost of informal payments (bribes). If the families did not have a mobile phone, they were interviewed outside the hospital on the last day of the women’s stay (8 cases). We calculated the price of drugs and pharmaceutical products prescribed for each patient from the time they were admitted to the hospital until leaving, based on prescriptions they showed the researcher. The Moroccan currency (MAD) was converted into US$ at a rate of US$ 0.127 for 1 MAD. The direct interview with the women and/or their carers enabled us to estimate the amount of informal payments and the cost of extra food. The families were also asked to list the total travel cost and the opportunity costs for the wife and her carer. For the woman, only the trip that ended in her admission to the hospital was taken into account. The travel cost of the main carer (return journey between home and the hospital) was multiplied by the number of visits during the hospital stay. Finally, we added the cost of the woman’s return journey on exiting the hospital. The extra cost for food and the opportunity costs were calculated only for the women who had a caesarean section but not for their companions. All the data from the questionnaires have been transcribed in variables, encoded in Excel 2007, and transferred to SPSS version 16.0 for statistical analysis. For some variables, we have calculated measures of frequency, central tendency and dispersion. The interviews were carried out by a male doctor, who introduced himself as a Masters student. The women and their family were informed about the study objectives, that they could refuse to participate, were free not to reply to certain questions or interrupt the interview at any moment without this having an influence on their quality of care. It was explained that their honest reply to the questions would help get a better understanding of the fee exemption actual process. They were assured that their replies would be treated confidentially and that their name would not be mentioned on any of the forms. At the end of this introduction, they were asked again about their consent to participating in the study. If they consented they were asked for a telephone number where they could be reached once they had left the hospital. In Morocco, the directors of the public hospitals guarantee the protection of hospitalized patients. A written authorization giving permission to carry out the study was obtained for each of the hospitals involved in the study.

Résumé de l’IA

Study Justification:

The study aimed to estimate the actual cost of caesarean sections in Morocco from the patients’ perspective. This was important because financial barriers are a significant obstacle to accessing emergency obstetric care and reducing maternal mortality. The study focused on the fee exemption policy for caesarean sections implemented in public hospitals in Morocco in 2009. The goal was to determine if the fee exemption policy truly provided free care or if other direct costs still existed.

Highlights:

– The study was conducted in April 2010 in three public hospitals in Fez, Morocco.
– Semi-structured interviews were conducted with 100 women who had given birth by caesarean section in these hospitals.
– The results showed that households paid between US$169 and US$291 for a caesarean section, depending on the hospital.
– The direct cost of a caesarean section was influenced by the price of drugs purchased by the families, the invoice paid at the university hospital, and transportation costs.
– The fee exemption policy for caesarean sections in Morocco had reduced the total cost for households without a poverty card, but it did not result in truly free caesarean deliveries.

Recommendations:

– Ensure that the fee exemption policy for caesarean sections in public hospitals is effectively implemented and monitored.
– Address the remaining direct costs associated with caesarean sections, such as the price of drugs, by exploring options for reducing or eliminating these costs.
– Improve access to poverty cards, which provide evidence of indigence and exempt individuals from paying for caesarean sections.
– Consider expanding the fee exemption policy to include the private sector, as the cost of caesarean sections in private hospitals is currently inaccessible for the poor.

Key Role Players:

– Ministry of Health (MOH): Responsible for overseeing the implementation and monitoring of the fee exemption policy for caesarean sections in public hospitals.
– Directors of public hospitals: Ensure the protection of hospitalized patients and provide authorization for research studies.
– Health professionals: Conduct interviews and provide healthcare services to women giving birth by caesarean section.
– Local authorities: Involved in the process of obtaining poverty cards, which exempt individuals from paying for caesarean sections.

Cost Items for Planning Recommendations:

– Essential drugs and consumables for caesarean sections: Budget allocation required to ensure an adequate supply of essential medicines and consumables in public hospitals.
– Transportation: Consideration of transportation costs for women and their companions to and from the hospital.
– Informal payments (bribes): Addressing the issue of informal payments and exploring strategies to eliminate or reduce these costs.
– Extra food: Taking into account the additional cost of food for women who undergo caesarean sections.
– Opportunity costs: Considering the potential loss of income or productivity for women and their companions during the hospital stay.
Please note that the cost items mentioned are for planning purposes and not actual cost estimates.

Force de la preuve

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study provides specific data on the actual cost of caesarean sections in Morocco and highlights the financial barriers to accessing emergency obstetric care. However, the sample size is relatively small (100 women) and the study was conducted in only three public hospitals in Fez, which may limit the generalizability of the findings. To improve the strength of the evidence, future studies could include a larger and more diverse sample from multiple regions in Morocco. Additionally, conducting a comparative analysis between public and private hospitals could provide further insights into the cost differences and accessibility of caesarean sections.

Abstrait

The principal investigator (PI) selected the three public referral hospitals in Fez district, Morocco, where he worked. These hospitals serve the city of Fez and the neighboring provinces (Taounat, Moulay Yacoub, Sefrou, Boulmane), a population of 1.7 million inhabitants (5.4% of the total Moroccan population) [9]. Two of the three hospitals, the provincial hospital (PH) and the regional hospital (RH), fall under the SEGMA system (governmental service managed autonomously) and the direct authority of the Ministry of Health (MOH). The third hospital, the university hospital (UH), is managed as an autonomous public institution. In 2009, the two SEGMA hospitals carried out 7952 vaginal deliveries and 1247 caesarean sections, while the UH carried out 4137 vaginal deliveries and 1002 caesareans. Besides these three, there are a number of private hospitals but the average cost of a caesarean in the private sector is higher than US$1000, which makes it inaccessible for the poor; moreover the decision to provide fee exemption for caesarean deliveries does not apply to the private sector. Normal (vaginal) deliveries have been free in the public small maternities since decades and are free since 2009 in public hospitals. Before the fee exemption policy, normal delivery had to be paid at a flat fee of $64 in public hospitals, except if the woman could bring the evidence of her indigence (thanks to a poverty card obtained from the local authority, a sometimes long and difficult process) or if she was covered by a health insurance (a small minority of the population). For a caesarean section, women had to pay a lump sum of $283 [10]. The additional costs for a vaginal delivery, due for instance to prescribed drugs, have not been investigated although these costs, in the experience of the investigators, were kept low. Tariffs have been abolished by the fee exemption policy. Initially, the MOH distributed delivery and caesarean kits in which the essential medicines and consumables were packed to all the public facilities. Later, in 2010, public hospitals got an additional budget to order the required essential drugs and consumables for deliveries and C-sections. The list of drugs is however limited to the WHO essential ones and usually are generic medicines. The information about household expenditure was collected between 1st and 30th April 2010, as part of the practical training of the PI, from a sample of 100 women who gave birth by caesarean section in one of the three hospitals: 68 in the RH (all women delivered by caesarean section in April 2010), 16 in the PH (interviews taken from all the women delivered by caesarean in the week of 16th to 23rd April 2010) and 16 in the UH (interviews of all the women delivered by caesarean from 19th to 30th April 2010). The women were interviewed together with their family at the moment they left the hospital (26 patients, 56 husbands and 18 accompanying persons (carers other than the husband)). The information about the direct cost of the caesarean section was collected through a questionnaire with a mix of open and closed questions. The first part, designed for the women and/or their carers immediately after the delivery consisted of face-to-face interviews. It was carried out inside the hospital and aimed at gathering information about the pregnancy and about the degree of knowledge about the fee exemption system for caesareans; and at putting the interviewed person (the husband in most cases) at ease. During this first interview the investigator also asked the consent of the interviewee to continue the interview at a later stage – once the patient had left the hospital – through a telephone survey. This latter part of the interview primarily focused on drug costs after leaving the hospital and the cost of informal payments (bribes). If the families did not have a mobile phone, they were interviewed outside the hospital on the last day of the women’s stay (8 cases). We calculated the price of drugs and pharmaceutical products prescribed for each patient from the time they were admitted to the hospital until leaving, based on prescriptions they showed the researcher. The Moroccan currency (MAD) was converted into US$ at a rate of US$ 0.127 for 1 MAD. The direct interview with the women and/or their carers enabled us to estimate the amount of informal payments and the cost of extra food. The families were also asked to list the total travel cost and the opportunity costs for the wife and her carer. For the woman, only the trip that ended in her admission to the hospital was taken into account. The travel cost of the main carer (return journey between home and the hospital) was multiplied by the number of visits during the hospital stay. Finally, we added the cost of the woman’s return journey on exiting the hospital. The extra cost for food and the opportunity costs were calculated only for the women who had a caesarean section but not for their companions. All the data from the questionnaires have been transcribed in variables, encoded in Excel 2007, and transferred to SPSS version 16.0 for statistical analysis. For some variables, we have calculated measures of frequency, central tendency and dispersion. The interviews were carried out by a male doctor, who introduced himself as a Masters student. The women and their family were informed about the study objectives, that they could refuse to participate, were free not to reply to certain questions or interrupt the interview at any moment without this having an influence on their quality of care. It was explained that their honest reply to the questions would help get a better understanding of the fee exemption actual process. They were assured that their replies would be treated confidentially and that their name would not be mentioned on any of the forms. At the end of this introduction, they were asked again about their consent to participating in the study. If they consented they were asked for a telephone number where they could be reached once they had left the hospital. In Morocco, the directors of the public hospitals guarantee the protection of hospitalized patients. A written authorization giving permission to carry out the study was obtained for each of the hospitals involved in the study.

Matériaux

N/A

Innovations

One potential innovation to improve access to maternal health is the implementation of a fee exemption policy for caesarean sections in Morocco. This policy aims to reduce financial barriers and improve access to emergency obstetric care, ultimately reducing maternal mortality rates. The fee exemption policy was implemented in public maternity hospitals in 2009, but this study conducted in Fez in 2010 found that households still incurred costs for caesarean sections, mainly due to the price of drugs, invoices from the hospital, and transportation expenses. The study highlights the need for further measures to ensure truly free caesarean deliveries.

AI Innovations Description

The recommendation to improve access to maternal health in Morocco is to further develop the fee exemption policy for caesarean sections. While the policy has reduced the financial burden for households, it has not resulted in truly free caesarean deliveries. To address this, the following steps can be taken:

1. Expand the fee exemption policy: Ensure that the fee exemption policy covers all direct costs associated with caesarean sections, including the price of drugs, transportation, and any other additional expenses.

2. Increase awareness: Conduct awareness campaigns to inform women and their families about the fee exemption policy and the services it covers. This will help ensure that eligible individuals are aware of their rights and can access the necessary care without financial barriers.

3. Strengthen implementation and monitoring: Improve the implementation and monitoring of the fee exemption policy to ensure that all eligible individuals receive the benefits. This can be done through regular audits, training of healthcare providers, and clear guidelines for the application of the policy.

4. Address gaps in the private sector: Explore options to extend the fee exemption policy to the private sector or develop alternative strategies to make caesarean sections more affordable for low-income individuals who seek care in private hospitals.

By implementing these recommendations, the fee exemption policy for caesarean sections can be further developed into an innovation that improves access to maternal health in Morocco.

AI Innovations Methodology

In order to improve access to maternal health in Morocco, one potential recommendation is to further enhance the fee exemption policy for caesarean sections. This would involve addressing the remaining direct costs that households still have to bear despite the fee exemption.

To simulate the impact of this recommendation on improving access to maternal health, a methodology could be developed as follows:

1. Define the objectives: Clearly outline the specific goals of the simulation study, such as assessing the potential reduction in financial barriers, estimating the cost savings for households, and evaluating the overall impact on access to caesarean sections.

2. Data collection: Gather relevant data on the current cost of caesarean sections from the patients’ perspective. This could involve conducting interviews or surveys with a sample of women who have undergone caesarean sections in public hospitals in Fez. Collect information on the direct costs incurred by households, including the price of drugs, invoices paid, and transportation expenses.

3. Analyze the data: Use statistical analysis software, such as SPSS, to analyze the collected data. Calculate measures of frequency, central tendency, and dispersion to understand the distribution of costs and identify any patterns or trends.

4. Develop a simulation model: Based on the analyzed data, develop a simulation model that represents the current situation regarding access to caesarean sections and the associated costs. This model should take into account factors such as the number of caesarean sections performed, the cost of drugs and consumables, and the transportation expenses.

5. Introduce the recommendation: Modify the simulation model to incorporate the proposed fee exemption policy enhancements. Adjust the relevant variables, such as reducing or eliminating the cost of drugs and consumables, and updating the transportation expenses.

6. Simulate the impact: Run the simulation model with the modified variables to simulate the impact of the recommendation. Evaluate the changes in costs for households, the potential increase in access to caesarean sections, and any other relevant outcomes of interest.

7. Analyze the results: Analyze the simulation results to understand the potential impact of the fee exemption policy enhancements. Assess the cost savings for households, the reduction in financial barriers, and the overall improvement in access to maternal health.

8. Draw conclusions and make recommendations: Based on the analysis of the simulation results, draw conclusions about the potential benefits of the fee exemption policy enhancements. Make recommendations for implementing and scaling up these enhancements to improve access to maternal health in Morocco.

By following this methodology, policymakers and stakeholders can gain insights into the potential impact of the recommended fee exemption policy enhancements on improving access to maternal health in Morocco.

Auteur

Dima Health

Statistics:

Citations: 12

Identifiers:

DOI: 10.1186/0778-7367-70-3

ISSN: 07787367

Research Areas:

Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health

Study Countries:

Morocco

Study Design:

Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Male & Female

Partagez ceci :