REMOVING USER FEES FOR KEY MATERNAL AND NEWBORN HEALTH SERVICES

Several NMR/MMR Exemplar countries implemented programs to eliminate user fees for essential maternal and newborn health services. In several countries, these programs were targeted to, or piloted in, regions that were historically poorer or had higher mortality levels. Services covered by these initiatives include vaginal deliveries, Cesarean sections, antenatal and postnatal care, as well as transportation costs. In many of the NMR/MMR Exemplar countries, progress in maternal and newborn health accelerated in the years immediately following the implementation of these policies, suggesting they played a crucial role in contributing to progress.

Country Spotlight: Senegal

Transitioned from phase X to phase Y between 2000 and 2020

Senegal mitigated financial barriers to facility-based delivery care through its 2005 National Free Delivery and Cesarean Policy, which eliminated user fees for all institutional births.¹ The policy was initiated in regions with lower access to care and a higher proportion of low-income households, including Kolda, Ziguinchor, Tambacounda, Matam, and Fatick.² Under this program, facilities are reimbursed by the government through the provision of supply kits valued at US$11 for vaginal deliveries and US$110 for Cesarean sections.¹ Our analysis using the Lives Saved Tool shows a notable increase in the number of lives saved through Cesarean sections and other facility-based interventions beginning in 2005 when this policy was introduced.

Learn more from other NMR/MMR Exemplar countries:

• India’s 2005 Janani Suraksha Yojana and 2011 Janani Shishu Suraksha Karyakram initiatives
• Nepal’s 2006 Safe Delivery Incentive Program
• Niger’s 2006 Fee Exemption Program
• Morocco’s 2008 and 2012 Acceleration Plans

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INCENTIVIZING UPTAKE OF MATERNAL AND NEWBORN HEALTH SERVICES

In addition to removing user fees, several NMR/MMR Exemplar countries implemented conditional cash transfer programs designed to encourage the use of key maternal and newborn health services and help ease the financial burden of care. Several initiatives combined approaches by removing user fees and offering conditional cash transfers. These programs typically offered direct deposits into the bank accounts of eligible recipients. In countries like Nepal and Bangladesh, the recipients were mothers and families, while in India, as described in the next section, health workers were also eligible for cash transfers.

Country Spotlight: India

Transitioned from phase X to phase Y between 2000 and 2020

In 2005, India launched the Janani Suraksha Yojana initiative, which was complemented by the establishment of a cadre of community health workers called Accredited Social Health Activists (ASHAs).³ Under these programs, eligible women were offered cash incentives if they delivered in government health facilities or accredited private facilities. All women in “lower-performing” states were eligible, and women living below the poverty line or belonging to marginalized castes in “higher-performing” states were also eligible. Within a year, the number of beneficiaries grew from 740,000 to 3.16 million, ultimately reaching about 11 million recipients by 2017-2018.^4,5 ASHAs are also eligible to receive performance-based incentives, based on factors such as the number of women they refer to health facilities for delivery.⁶

Learn more from other NMR/MMR Exemplar countries:

• Bangladesh’s 2007 Maternal Health Voucher Scheme
• Nepal’s 2006 Safe Delivery Incentive Program

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MITIGATING PHYSICAL AND LOGISTICAL BARRIERS TO CARE

Several Exemplar countries have also prioritized measures to promote the uptake of maternal and newborn health services beyond financial incentives. One such strategy is the expansion of maternity waiting homes, which offer a safe place for pregnant women to stay before delivery, reducing the risks associated with traveling while in labor. Other countries have focused on expanding networks of ambulance services that can help transport women to health facilities and, in cases of complications, can be valuable for referrals to higher-level health facilities.

Country Spotlight: Nepal

Transitioned from phase X to phase Y between 2000 and 2020

Nepal increased access to health facilities in rural areas by improving road networks and expanding networks of facilities in rural mountainous areas. By 2021, over 90% of the population could access a public health facility within a 60-minute walk or 15-minute drive.⁷ The network of facilities was expanded: every district in Nepal had at least one hospital by 2018, and the number of birthing centers and BEmONC sites rose from 291 sites in 2008 to 2296 sites in 2018. To reach women in particularly isolated areas, in 2018 Nepal launched the President’s Women Upliftment Programme, which provides free helicopter transport for deliveries involving complications such as prolonged labor or postpartum hemorrhage.⁸

Learn more from other NMR/MMR Exemplar countries:

• India’s “108” Ambulance Service
• Ethiopia’s Maternity Waiting Homes
• Morocco’s SAMU-OR Ambulances and Dar Al Oumouma Maternity Waiting Home Program

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STRENGTHENING LINKAGES BETWEEN COMMUNITIES AND THE HEALTH SYSTEM

Community engagement—often led by community health workers—is a common theme across NMR/MMR Exemplar countries. These health worker cadres play a crucial role in generating demand for maternal and newborn health services by raising awareness about the importance of seeking care and informing communities about available services, including incentive programs and the removal of user fees. Several NMR/MMR Exemplar countries have implemented approaches to engage and educate communities about maternal and newborn health. This is particularly evident in Ethiopia’s Health Extension Program, which includes educational modules about the benefits of key health services, as well as Niger’s husband schools, which aim to raise awareness about maternal health in settings where strong gender norms influence decision making.

Country Spotlight: Senegal

Transitioned from phase X to phase Y between 2000 and 2020

In 2014, Senegal introduced the National Community Health Policy to coordinate community-based interventions nationwide, following the establishment of a community health unit in the Ministry of Health and Social Action.⁹ The country also expanded its network of health posts and established five distinct cadres of community health workers, each with specific roles. These roles range from providing preventive care and home-based services to promoting behavior change and encouraging the use of maternal health services. One cadre, the Bajenu Gox, is unique to Senegal and is based on the traditional Senegalese social role of the Bajen, or paternal aunt. Typically older women selected from communities, Bajenu Gox serve as trusted advocates for women’s health, raising awareness about local maternal and child health issues.¹⁰ In 2020, Senegal had an estimated 25,000 community health workers.

Learn more from other NMR/MMR Exemplar countries:

• Bangladesh’s female community health workers
• Ethiopia’s Health Extension Program and Health Extension Workers
• India’s Accredited Social Health Activists (ASHAs)
• Morocco’s mobile medical units
• Nepal’s female community health volunteers (FCHVs)
• Niger’s Husband Schools

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UPSKILLING HUMAN RESOURCES FOR HEALTH AND TASK SHIFTING

In NMR/MMR Exemplar countries, lower-level providers were often upskilled to deliver lifesaving care, particularly in contexts with shortages of specialized health workers. Task-shifting strategies were implemented to enable these providers to take on responsibilities related to emergency obstetric and newborn care, supported by targeted training. These efforts were reinforced by the expansion of medical training centers and schools, alongside policies that incentivized providers to serve in rural or underserved areas with limited access to care.

Country Spotlight: Ethiopia

Transitioned from phase X to phase Y between 2000 and 2020

Ethiopia faced a shortage of physicians and gynecologists trained to perform Cesarean sections and other emergency obstetric procedures. To address this, the Ministry of Health partnered with local and global partners to develop training programs to empower non-physician health professionals to fill this critical need. In 2009, a three-year master’s level training program was established at three Ethiopian universities for health professionals who already had at least a bachelor of science degree and a minimum of two years of work experience. Assessments of this cadre—known as Integrated Emergency Surgery and Obstetrics providers—indicate that they are capable of delivering high-quality care for patients requiring emergency obstetric services.¹¹

Learn more from other NMR/MMR Exemplar countries:

• India’s Daksh and Dakshata skills labs
• Morocco’s 2008 Acceleration Plan’s expansion of in-service training
• Senegal’s Regional Health Training Centers and nurse/midwife-led health posts
• Nepal’s task-shifting to mid-level providers for reproductive health services