financial implications of skilled attendance at delivery in nepal

Financial implications of skilled attendance at delivery in Nepal

Josephine Borghi1, Tim Ensor2, Basu Dev Neupane3 and Suresh Tiwari4

1 Maternal Health Programme, London School of Hygiene and Tropical Medicine, London, UK2 Oxford Policy Management, Oxford, UK3 Freelance Consultant, Chhauni, Kathmandu, Nepal4 Freelance Consultant, Department of Public Health, Purbanchal University, Kathmandu, Nepal

Summary objective To measure costs and willingness-to-pay for delivery care services in 8 districts of Nepal.

method Household costs were used to estimate total resource requirements to finance: (1) the current

pattern of service use; (2) all women to deliver in a health facility; (3) skilled attendance at home

deliveries with timely referral of complicated cases to a facility offering comprehensive obstetric services.

results The average cost to a household of a home delivery ranged from 410 RS ($5.43) (with a friend

or relative attending) to 879 RS ($11.63) (with a health worker). At a facility the average fee for a

normal delivery was 678 RS ($8.97). When additional charges, opportunity and transport costs were

added, the total amount paid exceeded 5300 RS ($70). For a caesarean section the total household cost

was more than 11 400 RS ($150). Based on these figures, the cost of financing current practice is 45 RS

($0.60) per capita. A policy of universal institutional delivery would cost 238 RS ($3.15) per capita

while a policy of skilled attendance at home with early referral of cases from remote areas would cost

around 117 RS ($1.55) per capita. These are significant sums in the context of a health budget of about

400 RS ($5) per capita.

conclusions The financial cost of developing a skilled attendance strategy in Nepal is substantial. The

mechanisms to direct funding to women in need must to be improved, pricing needs to be more

transparent, and payment exemptions in public facilities must be better financed if we are to overcome

both supply and demand-side barriers to care seeking.

keywords safe motherhood, skilled attendance, costs, financing

Introduction

Improving maternal and infant health is a major focus of

the current national development plan in Nepal (HMGN

2002), yet extension of safe motherhood programmes has

made limited headway and measures of mortality and use

of services have improved little since the beginning of the

1990s. Nepal’s maternal mortality ratio is among the

highest in Asia, estimated at around 539 per 100 000 live

births (Pradhan et al. 1997). The government is committed

to reducing maternal mortality. The recent Health Sector

Programme Implementation Plan set a target rate of 300

per 100 000 by 2009 (HMGN 2003).

Despite international recognition of the importance of

skilled attendance in maternal mortality reduction (Gra-

ham et al. 2001), more than 90% of women in rural Nepal

deliver at home with relatives or alone (Pradhan et al.

1997; Osrin et al. 2002). Socio-cultural factors impeding

use of obstetric services include high rates of illiteracy,

especially in rural areas where less than 27% of women can

read or write (HMGN 2001). Many women also prefer the

home environment and to deal with problems within the

community rather than seek help from outside (Mesko

et al. 2003). Limited geographic access to health services is

a further barrier particularly in hill and mountain districts

(Furber 2002). Although the limited quality of health

services in rural communities is an even greater deterrent to

service use (Acharya & Cleland 2000; Jahn et al. 2000;

Hotchkiss 2001). All these factors are compounded by the

ongoing disruption caused by the Maoist insurgency,

which affects service delivery in many areas (Thapa 2003).

The affordability of obstetric health services is a further

determinant of care seeking (Mbuga et al. 1995; Owa et al.

1995; Wilkinson et al. 2001). Evidence from sub-Saharan

Africa and South Asia indicates that households often

spend significant amounts for delivery care (Nahar &

Costello 1998; Levin et al. 2000), especially if complica-

tions arise. Hospital costs associated with a dystocia case

accounted for 34% of annual household income in Benin

(Borghi et al. 2003). Whilst cost is known to impact on

demand for maternity care, little is know about how

charges are set within facilities, and if and how exemptions

Tropical Medicine and International Health doi:10.1111/j.1365-3156.2005.01546.x

volume 11 no 2 pp 228–237 february 2006

228 ª 2006 Blackwell Publishing Ltd

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https://www.researchgate.net/publication/8976383_Costs_of_near-miss_obstetric_complications_for_women_and_their_families_in_Benin_and_Ghana?el=1_x_8&enrichId=rgreq-c1d1ce89-b22c-4420-9ad7-4887b007f3b5&enrichSource=Y292ZXJQYWdlOzczMjMzOTg7QVM6MTAyMzM1MDMyMzMyMjk3QDE0MDE0MDk5ODEzMDE=

for the poor are enforced. Distance from a facility adds to

the financial burden facing households through transport

charges and time spent away from productive activity

(Kowalewski et al. 2002), although indirect costs have

received less attention in the literature.

Much of the past strategy to improve maternal services

in Nepal has focused on increasing the volume of service

providers, and hence reducing the time and transport costs

facing women (Hotchkiss 2001). This is still a core part of

current activity although more emphasis is now being

placed on demand side factors that impede access to

services. The importance of addressing both supply and

demand-side barriers simultaneously has been suggested in

a number of international studies (Maine 1997; Koblinsky

2003).

Against this background, the DFID-financed Nepal Safer

Motherhood Project (NSMP), run by Options, has sup-

ported the Government’s own National Safe Motherhood

Programme since 1997 by seeking to improve service

quality in facilities and communities and to reduce access

barriers. While cost has been identified as a major barrier

to care seeking, there have been no detailed or systematic

attempts to measure their full impact in Nepal.

We report on a recent study undertaken for the NSMP to

quantify the financial barriers to delivery care seeking for

households in Nepal and predict the resource implications

of increasing skilled attendance at delivery in different

settings. More detailed information is provided in the main

report (Borghi et al. 2004).

Materials and methods

Background

To measure the household cost of delivery care and better

understand household coping strategies, we conducted a

study between September and November 2003 in eight

districts of Nepal1. The objectives were:

(1) to assess the financial implications of delivering with

different levels of assistance: alone or with an

untrained attendant at home (a relative or untrained

traditional birth attendant), with a trained traditional

birth assistant or a skilled health professional, or in a

hospital;

(2) to determine household willingness-to-pay for each

type of service;

(3) to determine user charges and exemption policies

within health facilities;

(4) to estimate the cost to the government of providing

delivery care in one zonal hospital.

We distinguished carefully between demand-side costs,

incurred outside of the facility during the process of care

seeking, and facility-based costs, payments made by

patients at the facility during the treatment process. This

distinction is important since most public systems finance

at least some facility-based costs while often neglecting

costs incurred outside, although these can constitute a large

financial barrier.

Study design

Two household surveys were carried out estimating both

the costs of delivery care (1) and willingness-to-pay (2).

Two samples of a total 720 women were selected for

interview. Within each district, households were selected

from three village development committees2 stratified by

distance from the district centre (close, medium distance

and far3), as described in Borghi et al. (2004). Briefly,

women who had given birth in the previous year were

identified with the assistance of community health work-

ers. All those who had given birth in a hospital were

interviewed. In addition, 10 women who gave birth at

home with a trained attendant and 10 who delivered with

an untrained attendant were chosen at random from each

VDC, totalling 90 women per district. Facility-based costs

were derived from patient records at hospitals. The

estimation of all other costs relied upon household recall

over a period of between a month and a year (Table 1)4. In

order to inform public sector policy, we present here the

costs incurred in public hospitals for vaginal deliveries and

caesarean sections.

For the willingness-to-pay survey thirty married women

of reproductive age were selected randomly from each

village development committee. Women were first asked to

express a preference for place of delivery and attendant.

1 Stratified in terms of NSMP presence and topography: NSMP -

Kailali (plain), Sukhet & Baglung (hill), Jumla (mountain) and

Non-NSMP - Jhapa (plain), Gulmi & Bhojpur (hill) and Dolpa(mountain)

2 An administrative region covering around 60 square kilometres

and an average population of 7000.3 For the plain districts, near was defined as less than an hour

walking; medium between 1 - 2 hours; and far, more than 2 hours.

In hill and mountain districts, near was defined as less than 2 hourswalking or local transport; medium between 2-8 hours, and far

more than 8 hours.4 We were unable to interview women at facilities, because it

would have taken too long to obtain a sufficient sample size andbecause women may have been reluctant to respond honestly

about informal costs whilst in the facility. However, our findings

indicated little difference between reported facility-based costs andhospital bills, suggesting that recall bias was minimal.

Tropical Medicine and International Health volume 11 no 2 pp 228–237 february 2006

J. Borghi et al. Financial implications of skilled attendance at delivery in Nepal

ª 2006 Blackwell Publishing Ltd 229

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https://www.researchgate.net/publication/12165194_Expansion_of_Rural_Health_Care_and_the_Use_of_Maternal_Services_in_Nepal?el=1_x_8&enrichId=rgreq-c1d1ce89-b22c-4420-9ad7-4887b007f3b5&enrichSource=Y292ZXJQYWdlOzczMjMzOTg7QVM6MTAyMzM1MDMyMzMyMjk3QDE0MDE0MDk5ODEzMDE=

Options considered were: a comprehensive obstetric facil-

ity; a basic obstetric facility; a trained attendant at home;

an untrained attendant at home. They were asked for the

maximum they would be willing to pay to give birth for

each option. The survey employed an open-ended question

format5 that was felt to be suitable in a context where

households are used to paying for medical services. The

scenario referred to a future (hypothetical) pregnancy, and

therefore, women did not know whether the outcome

would be a normal vaginal or a surgical delivery and so

were required to make an implicit judgment about relative

risk.

To estimate socio-economic status for households in

both surveys, we used the asset index approach, which

ranks households on the basis of ownership of key durable

items (Gwatkin 2002). The durable items selected were

those used in the demographic and health survey 2001

(HMGN 2001). Quintiles were derived by ordering

households by their total asset score and dividing then into

five groups of equal size.

A facility survey was conducted with key informants

from each of the district hospitals, to assess how fees were

set for maternity care and exemption policy and practice

for the poor.

To estimate the recurrent costs to government of

providing maternity care in a zonal hospital, we conducted

a small study using step-down accounting methods based

on an adapted version of the WHO Mother and Baby

Costing Package6. This study indicated that household

direct payments for delivery care amounted to more than

90% of the unit cost of providing these services. Costs

derived from the household survey were then used to

estimate resource requirements for financing the demand-

side and recurrent facility-based costs of three scenarios for

skilled attendance coverage in Nepal. Given the variation

in household costs between geographical areas, two typical

district ‘types’, plain and mountain/hill, were considered,

each with an average crude birth rate of 3.4%. A strategy

of skilled attendance at delivery includes both availability

of skilled attendants (suitable to the level of care provided),

necessary supplies and equipment and provision of referral

mechanisms to get women to more comprehensive facilities

when required (Graham et al. 2001). Currently use of

health facilities in Nepal is low (around 56% bed

occupancy in 2002 which still leaves around 0.6 million

bed-days available). This suggests that some increase in

health service use could be absorbed within the existing

inpatient infrastructure. For example, providing 4 days of

inpatient care to emergency cases (15% of all delivery

cases) would require around 0.5 million bed-days and

could be met within the existing infrastructure. With this in

mind, we examined total and per capita costs of several

scenarios.

Current situation. The first scenario comprises current

coverage levels with around 93% of deliveries taking place

at home, caesarean section rates of 0.8%7. and other

complications, including sepsis, haemorrhage and

eclampsia accounting for a further 1.2% of deliveries in

facilities.

Institutional delivery. The second scenario considers that

all women deliver at a health facility, with a complication

rate of 15%. This provides an indication of the upper limit

cost of increasing skilled attendance coverage. However,

implementation in the short term would be impractical

given insufficient human and infrastructural capacity8. and

lack of community acceptance given the preference for

home deliveries.

Table 1 Classification of household costs

Type of cost Facility Home

Facility-based fees Registration, delivery fee, bed charge, laboratory tests,laundry, food, drugs and medical supplies

Not applicable

Additional charges Gifts to staff and medicines and other items purchased

by patients together with the value of food and

washing materials brought in from outside the facility

Gifts to attendant and medicines,

food and washing materials and a

safe delivery kit where relevantTransport fees To and from the facility Not applicable

Opportunity cost of time Valuation of the time of those accompanying the woman

to the facility

Assumed to be zero since attendants

can continue with other activities

5 How much would be the maximum you would be willing to pay

for?6 http://www.who.int/reproductive-health/economics/intro.html

7 Based on estimates from the 2001 Demographic and Health

Survey (HMGN 2001).8 Over 1.3million bed days would be required which is more thantwice the existing spare capacity.




https://www.researchgate.net/publication/239924607_Can_Skilled_Attendance_at_Delivery_Reduce_Maternal_Mortality_in_Developping_Countries?el=1_x_8&enrichId=rgreq-c1d1ce89-b22c-4420-9ad7-4887b007f3b5&enrichSource=Y292ZXJQYWdlOzczMjMzOTg7QVM6MTAyMzM1MDMyMzMyMjk3QDE0MDE0MDk5ODEzMDE=

Skilled attendance at home with early referral of remote

cases. This scenario is based on skilled attendants for

home deliveries with referral to a comprehensive essential

obstetric care facility in the event of complications. Skilled

attendants are defined here as a medical professional with

midwifery training. The unit cost of a ‘skilled’ home

delivery includes the attendant’s time based on the charges

reported by surveyed women plus the value of a safe

delivery kit (950 RS). We assume that all complicated cases

(15%) would be treated in a hospital and that women

living in mountain districts and more than 2 hours away

from a facility (approximately 40%) would move closer to

the facility prior to the onset of labour, either to stay with a

relative, or to stay in a basic obstetric care facility or a

waiting home9. Transport to the health facility and delivery

care costs but not ‘waiting costs’ of these 40% are included

in the calculations.

All costs are presented in Nepali Rupees (RS) and US

Dollar equivalents using the average official exchange rate

for 2003, $1 ¼ RS 75.55. Data were analysed using SPSS.

Results

Costs of delivery care and willingness-to-pay

The household survey found that the average cost for a

home delivery was 693 RS ($9.17) mostly comprising

payments to attendants. The difference between the cost of

a delivery attended by a medical professional (879 RS/

$11.63) and one assisted by a traditional birth attendant,

trained or untrained (759 RS/$10.05), was small. The cost

of a delivery attended by a friend or relative was much

lower (410 RS/$5.43).

The average facility-based fee for a normal delivery was

not significantly different from the total expenditure

incurred by those delivering at home (678 RS/$8.97,

Table 2). However, once the cost of transport (2812 RS/

$37.22), additional items (1354 RS/$17.92) and compan-

ion time (492 RS/$6.51) are added, the facility becomes

much more expensive (total RS 5336/$70.63).

Women undergoing caesarean section incurred signifi-

cantly higher costs in the facility with an average charge of

5500 RS ($72.80) excluding transport and other costs of

care. While there was little difference in facility-based costs

between geographic areas, the costs of transport varied

widely from an average of 1155 RS ($15.29) in flat plains

to 3100 RS ($41.03) in hills or mountains. In mountainous

districts women spent an average of 8.3 hours reaching a

comprehensive essential obstetric care facility; in hilly

districts, 5.6 hours and in flat districts, 2.8 hours. Moun-

tain dwellers were generally carried by stretcher or doko

(cane basket) although some travelled by plane.

Not only were the costs of facility-based delivery

considerable but, unlike home delivery, they varied con-

siderably. Variation in costs was greatest for transport and

additional items, where the 95% confidence interval

exceeded 30% of the mean (compared to less than 20% for

the facility-based fee). The confidence interval for the cost

of a c-section exceeded 50% of the mean.

For those in the poorest fifth of households, the cost of a

normal delivery in a facility represented 3 months of

household income compared to just over 1 month in the

richest group of households (Table 3). In case of obstetric

complications, seeking care for the poorest has catastro-

phic financial implications. More than a fifth of women

delivering at home said that cost was the main reason for

not delivering at a facility. The facility survey indicated

that most public hospitals claim to fully or partially exempt

poor women from charges. In practice, however, the actual

cost to households was found to vary little by economic

group.

Table 2 Household costs of institutional delivery care (Nepali Rupees), 95% confidence intervals in brackets

Home n ¼ 470 (%) Vaginal n ¼ 114 (%) C-section (n ¼ 12) (%)

Facility-based fees 678 (539–817) 12.7% 5500 (2697–8304) 48.1%Additional charges 693 (592–795) 100% 1354 (899–1810) 25.4% 1469 ()229–3166) 12.8%

Transport fees 2812 (1968–3656) 52.3% 2812 (1968–3656) 24.6%

Opportunity cost of time 492 (368–616) 9.2% 1660 (15–3305) 14.5%

Total 693 100% 5336 100% 11 441 100%

Table 3 Cost as a proportion of monthly cash income by wealth

group*

Place of delivery Poorest group Wealthiest group

Home 36% 1%

Public hospital vaginal 366% 113%

*Based on wealth groups derived from an index of asset owner-

ship.

9 Evidence suggests that the maximum time that women should be

from a CEOC facility in the event of haemorrhage is aroundtwo hours (UNICEF 1997).




The willingness-to-pay survey indicated that most

women (56%) preferred to give birth at home, in the

absence of complications. The main reasons given were:

the low cost and flexible payment mechanism allowed by

informal attendants, no need to travel, and the familiarity

of attendants and the home environment. A third of all

women preferred to deliver at a comprehensive obstetric

facility. Safety and staff experience were highlighted as the

main reasons for this preference. 34% of these women

were from the highest wealth quintile, compared to only

8% from the lowest.

On average women were willing to pay up to 733 RS

($9.70; median 500 Rs/$6.62) for a delivery at home with a

trained attendant. Those who preferred to deliver at a

comprehensive essential obstetric care facility (one-third)

were willing to pay RS 4886 ($64.67) on average.

Willingness-to-pay for a basic obstetric care facility was

much lower: 1452 RS ($19.22). Fifteen per cent of women

with preference for delivery in a health facility were not

willing-to-pay anything.

Costs of extending skilled attendance

The per capita costs of each scenario described in the

previous section are shown in Figure 1 for plain and

mountain/hill districts. The cost of financing the current

situation (Scenario 1) was estimated at an average 45 RS

($0.60) per capita (weighted average of costs in mountain

and plain districts). A policy of fully institutional delivery

(scenario 2) was estimated to cost an average 238 RS

($3.15) per capita while the skilled attendance at home

scenario (scenario 3) was estimated to cost 117 RS ($1.55).

These are substantial sums, considering the total per capita

public sector expenditure on health of around 400 RS

($5.29) (HEFU 2003).

The cost of developing blood banking capacity and

demand-creation within communities have been estimated

at around $0.37 per capita (Ensor 2004; Poudyal 2004).

When these are included, average per capita cost of the

skilled attendance at home strategy (Scenario 3) increases

to $1.90. This equates to more than $40 million per year

across the country or almost 40% of total public spending

on health care between 2001 and 2003 (HEFU 2003).

Discussion

Nepalese women delivering in health facilities face signi-

ficant costs both in accessing services (demand-side) and at

the facility. The costs incurred represent a considerable

proportion of household resources, especially for the

poorest. To improve accessibility and equity of service

provision, the full extent of the financial burden needs to be

taken into account.

While facility-based costs of normal delivery were

relatively modest, those for emergency care (caesarean

section and other complications10) imposed a heavy burden

on households. Obtaining sufficient cash to cover these

costs inhibits many from accessing institutional care and

delays the decision to seek care: 34% of those attending a

facility reported delaying their decision to seek care by an

average of 8 hours.

-

50

100

150

200

250

300

350

Per

cap

ita c

osts

(N

RS

)

Transport 3.71 17.76 41.27 197.29 9.29 66.58Opportunity cost 2.62 2.62 22.68 22.68 9.72 11.60Additional 25.69 25.69 46.62 46.62 35.98 37.52Facility Based 6.67 6.67 47.64 47.64 29.78 32.37

Scenario one (Plain)

Scenario one(Mountain/Hill)

Scenario two(Plain)

Scenario two(Mountain/Hill)

Scenario three(Plain)

Scenario three(Mountain/Hill)

Transport

Opportunity cost

Additional

Facility Based

Figure 1 Costs of alternative servicedelivery scenarios. Scenario 1: existing

pattern of home and institutional delivery;

scenario 2: fully institutional delivery; and

scenario 3: skilled attendance with earlyreferral of remote cases.

10 Due to small numbers, we could not estimate the costs of

assisted deliveries, but they are assumed to lie somewhere betweenthat of a normal delivery and a c-section.




Furthermore, households face considerable uncertainty

regarding the total amount of money they are likely to need,

due both to uncertainty of clinical need and also because

facilities tend not to publish tariffs. None of the facilities

examined provided package services with a standard price

for the entire episode of care. There is also little consistency

in pricing between pharmacies; similar prescriptions cost

vastly different amounts (MacDonagh & Neupane 2003).

Encouraging or even requiring public facilities to develop

standard charges for services that are then widely publicised

could help substantially. The charges would have to go

beyond the facility-based fee to include at least some of the

additional items paid for by households. Current informal

incentives are an important obstacle to this. It is well known

that many medical staff who practise privately receive rent-

free premises from pharmacies in return for referring

patients for prescriptions. The lack of transparency in what

is required and included in the standard facility bill provides

ample opportunity for this informal activity. Childbirth is

an expense that households have time to plan for, but to do

this they require a better idea of the amount of money that is

required.

The study suggests that there is little difference, partic-

ularly at the facility level, between the costs of care for the

rich and the poor, despite national guidelines that require

public facilities to exempt the most vulnerable.

These guidelines appear to fail partly because exemptions

are ad hoc and partly because there is little external

financing. Public health facilities are increasingly forced to

rely on user charges to finance services. Global experience

suggests that exemption mechanisms are only effective

when external funding is provided that is transparently

earmarked for this purpose (Bitran & Giedion 2003).

However, even if the exemption system worked effectively,

it would only apply to a relatively small portion of the total

cost incurred by households (facility-based fees accounting

for 13% of the total cost of a normal delivery and 48% of

the cost of a caesarean section, Table 2).

Our measurement of socio-economic status was based

on a weighted sum of household assets, which may be seen

as an imperfect proxy for permanent income. However,

this approach has been validated in Nepal, where little

difference was found between estimated consumption and

the asset index as a means of measuring socio-economic

inequality in malnutrition amongst under-five children

(Wagstaff & Watanabe 2003). The asset approach was

also found to be well correlated to the actual income

reported by the households in our survey suggesting it is a

valid measure of socio-economic status.

Many of the costs to the household are incurred outside

the facility and before treatment is obtained. Our study

indicates that the fees charged by health facilities for a

normal delivery are roughly comparable to the total

expenditure incurred for a home delivery. The difference

lies in transport and additional costs incurred together with

the opportunity costs of companions. If the state is to cover

some or all of the fees for hospital services then either

resources must be provided to women in communities or

some guarantee of funding these additional demand-side

costs. Without this guarantee households are unlikely to

take the major step of seeking institutional care.

Funds at the community level have been set up by

women’s groups and cooperatives in a number of districts

to alleviate some of the demand-side costs. However, like

micro-finance initiatives in other countries, these funds

tend not to be used by the poor who cannot afford to repay

the loans provided (Neupane 2004). The funds’ impact

seems to be limited as less than 2% of women we

interviewed reported them to be their main source of

finance used to pay for care. This could be due either to

insufficient cash within the funds, or lack of management

capacity to stop defaulters (Shehu et al. 1997).

Other mechanisms for solving the problem of limited

cash availability in poor households are therefore needed to

reduce demand-side barriers, especially for those in remote

areas. While there are a number of possible modalities,

such as vouchers and external subsidies for community

funds, it is important to develop mechanisms to reach those

most in need and to overcome demand-side barriers within

communities. For women in remote communities free

facility-based care is unlikely to be a sufficient incentive to

use them.

While it is already part of the Government’s strategy to

increase the number of health facilities, reducing transport

costs, relatively little attention has been paid to other

demand side costs. Ways of tackling them are usually

relegated to sub-components of donor-financed projects.

Yet these costs represent the largest component of cost for

women having a normal delivery in a facility. An important

decision is the extent to which accessibility should be

improved by extending the supply network or by improv-

ing referral to existing facilities. This is not an either/or

choice; a combination of improved financing for demand-

side costs and early referral in remoter areas together with

an increase in the number of comprehensive essential

obstetric care facilities is likely to be desirable. This

suggests the need for cost-effectiveness analyses comparing

a marginal increase in facilities to demand-side subsidies. It

may also require a policy reconsideration to allow

Government to invest in demand creation as well as service

delivery.

In Nepal, where accessibility is a major barrier, such a

strategy cannot be confined to speedy referral of compli-

cations once a woman is in labour. The problem with a




more ‘conservative referral’ strategy is that there is much

evidence that approaches for identifying high risk women

through antenatal care prior to labour are substantially

flawed (Carroli et al. 2001). Scenario 3 tackles this differ-

ently, by attempting to ensure that all women in remote

areas are within reach of a CEOC facility prior to the onset

of labour.

Another approach would be to bring comprehensive

essential obstetric care services closer to remote popula-

tions. The principal way of doing this is by upgrading basic

obstetric facilities with operative and blood transfusion

capabilities. Women might also be treated at a basic care

facility in a way that at least provides first aid for

complications through, for example, the use of misoprostal

to control haemorrhage. Given the reluctance of many

women in Nepal to leave their homes and seek early

facility-based care, this may well be more culturally

appropriate. Such changes do, however, have substantial

investment implications and the relative cost-benefit of

demand vs. supply-side interventions requires further

investigation.

What is the correct mix of public and private funding for

services?

An extremely limited public budget together with signifi-

cant demand-side costs means that developing a compre-

hensive financing strategy for safe motherhood will be

difficult. Our scenarios indicate the high costs of extending

skilled attendance coverage even when based on home

delivery for most uncomplicated births. This amounted to

almost 40% of total public spending on health care

between 2001 and 2003 (HEFU 2003). This is only the cost

of the safe-motherhood component of an essential package

and not the entire cost of a mother and baby package. Cost

sharing between households and government is therefore

inevitable if rates of skilled attendance at delivery are to

increase in a financially sustainable way. One way to

consider this issue is to decide on those costs that should

properly be financed from public vs. private sources. While

there are no clear rules on how different items should be

financed some possible guidance is presented in Table 4.

The study indicates that most households are willing

and, since contributions appear to vary with income, able

to finance home based costs of delivery care. Most women

preferred to deliver at home with a trained attendant.

Public funding of safe delivery kits and a greater provision

of skilled attendants with midwifery training is required,

but all but the poorest households might be expected to

contribute to costs.

At the facility level the willingness-to-pay study again

shows that cost sharing is accepted for the least poor.

The high value ascribed to comprehensive compared

to basic obstetric care (in many cases exceeding ability

to pay) indicates the recognition of the necessity of life

saving treatment in the case of real need. However,

it is important to note that the valuations given by

the willingness-to-pay survey overall closely mirrorred

the actual costs of care, suggesting that in contexts

where households are used to paying for health care,

expected price will influence valuations and not

necessarily reflect the service’s real worth to the

individual.

Payment for additional services could be dealt with in

several ways. Items, which are essential to the delivery but

currently procured by households, such as antibiotics or

oxytocin, might be included in a fixed tariff set by the

health facility so that the poor can be exempt from these

costs. Other costs, such as food and washing materials,

could be left to households.

Table 4 Costs to be financed publicly or privately

Type of cost

Household type

Non-poor Poor

Home based delivery Paid for by the household – based on WTP.

Possible public provision of safe delivery kits

Subsidised by government or through a

system of community financingFacility-based delivery

Facility-based fees Fully subsidised for complications and emergencies,

part-subsidy for normal deliveries

Fully subsidised

Additional charges Drug and unofficial charges absorbed into facility tariff,

costs of food and washing materials financed by households

Drug and unofficial costs absorbed into

facility tariff, costs of food and washing

materials financed by households

Transport fees Pooled community financing (loan funds, insurance) Grant subsidy (vouchers?) especially inmore remote areas

Opportunity costs Household May require a financial incentive




Transport costs are an important barrier where public

intervention is required. Public funding for transport costs

for low-income households is necessary since community

schemes cannot, on their own, provide sufficient cross-

subsidy. It remains an open and researchable question

which mechanism should be used to channel purchasing

power to those requiring assistance.

Public financing for opportunity costs is likely to be

difficult and perhaps contentious. These are not costs

that are readily amenable to reimbursement, since there

is no bill and costs vary from household to household.

Those with highest costs may come from wealthier

households. From this perspective it would seem justified

that they be financed by households. Yet, for some

households, the lost production may be a substantial

obstacle to using services. One approach would be to

provide grants (or payments) to low-income families to

cover the costs of transport and other expenses such as

opportunity costs. This amounts to a payment for

treatment which has been tested with some success in

other countries, for example, increasing compliance with

directly observed therapy for tuberculosis, childhood

vaccinations and schooling (Giuffrida & Gravelle 1998;

Gertler 2000).

The selected approach to cost sharing will impact on the

estimated resource requirements for each scenario to

increase skilled attendance coverage. If, for example a

policy of free delivery care were pursued that finances all

facility charges based on Scenario 3, the resource require-

ments would amount to some $10 million a year. Subsi-

dising transport costs by 50% for all those falling below

the poverty line (around 48% of the population) would

cost a further $2.5 million. Further costs may be incurred

in training and supervising midwives to provide skilled

attendance particularly at home where supervision is much

more difficult. These costs are not included here but would

need to be. It is likely that the cost of the most realistic

strategy will lie somewhere between Scenario 1 and 3.

Additional public money would be required to fund such a

strategy, although the resource requirement would increase

only as fast as services were extended to more remote

districts. When formulating policy, governments must

consider both short and longer run costs of any strategy to

increase the coverage of skilled attendance at delivery and

ensure that these can be financed from domestic or external

sources.

Our results give baseline (Scenario 1) and upper (Scen-

ario 2) estimates on the cost of delivery care together with

a possible transitional stage that is costed to allow for more

women in remote areas to obtain access to services. There

are clear limitations with this third scenario. The cultural

preference for home delivery may mean that women are

reluctant to move closer to a facility before a delivery even

with financial incentives. The 15% estimate of complica-

tions is based on post-delivery experience and in practice a

larger number of women may need to be referred to a

facility based on antenatal or early intra-partum indica-

tions. If this were so, the costs could approximate

Scenario 2 as the number of facility-based deliveries

increases. A final issue with promoting this strategy is that

women may have difficulty differentiating between for-

mally trained health workers and other types of attendant

such as trasditional birth attendants.

The Nepalese Government is now moving ahead with a

scheme to provide financial incentives for women deliver-

ing at a health facility and additional incentives for health

workers to attend deliveries at home. This is proposed at a

national level although it remains to be seen to what extent

the mechanisms can be extended to the more remote

districts in a way that has a significant impact on the rate of

skilled attendance at delivery.

Acknowledgements

This work was carried out for the NSMP managed by

Options Consultancy Services as part of HMG Nepal Safe

Motherhood Programme with the financial support of

DFID. We are grateful for the guidance of Melissa Cole,

Alison Dembo Rath, Hom Nath Subedi, Greg Whiteside

and Sandra MacDonagh. We are also grateful to all those

that participated in the household and facility surveys and

the work of the field interviewers. None of the above is

responsible in any way for errors of fact or interpretation

in this article of the underlying report.

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Implications financieres dans l’accouchement avec assistance qualifiee au Nepal

objectifs Mesurer les couts et la volonte de payer pour les soins d’accouchement dans huit districts.

methode Les depenses familiales ont ete utilisees pour estimer les ressources totales requises pour financer: (1) le profil en cours des services utilises, (2)

l’accouchement de toutes les femmes dans un service de sante et (3) l’accouchement a domicile avec une assistance qualifiee, incluant un transfert a temps

des cas compliques dans un cadre offrant des services obstetriques approfondis.

resultats Le cout moyen par foyer pour l’accouchement a domicile variait de 410 RS ($5,43) (avec assistance d’un amie ou d’un parent) a 879 RS

($11,63) (avec un professionnel de la sante). L’accouchement normal dans un service specialise revenait a 678 RS ($8,97). Quand on ajoute les frais

supplementaires, l’opportunite et le transport, le cout total pour le foyer revenait a plus de 5,300 RS ($70). Pour une cesarienne le cout total par foyer

depassait 11,400 RS ($150). Sur base de ces donnees, le cout pour le financement des services en cours etait de 45 RS ($0,60) par capita. Une politique

pour un accouchement institutionnel universel couterait 238 RS ($3,15) par capita alors que l’accouchement a domicile assiste d’une personne qualifiee

avec le transfert des cas des zones eloignees couterait environ 117 RS ($1,55) par capita. Ces sommes sont importantes dans le contexte d’un budget

pour la sante d’environ 400 RS ($5) par capita.

conclusion Le cout financier pour le developpement d’une strategie d’accouchement avec une assistance qualifiee est important. Les mecanismes pour

l’orientation des financements vers les femmes dans le besoin doivent etre ameliores. Les tarifications doivent etre transparentes et les exemptions au

paiement dans les services publiques doivent etre mieux equilibrees si nous sommes amenes a vaincre les barrieres a la fois du cote de l’offre et de la

demande dans les recours aux soins.

mots cles maternite saine, assistance qualifiee, couts, financement

Implicaciones financieras de la atencion cualificada en el momento del parto en Nepal

objetivo Medir el costo y la voluntad de pago por servicios de cuidado durante el parto en ocho distritos.

metodo Se utilizaron los costos familiares para estimar los recursos totales requeridos para financiar: (1) el patron actual de servicio utilizado; (2)

todas las mujeres que dan a luz en una unidad sanitaria; y (3) atencion cualificada en partos domiciliarios con transferencia oportuna de los casos

complicados a un centro que ofrezca servicios obstetricos completos.

resultados El costo familiar promedio de un parto domiciliario estaba entre 410 RS ($5.43) (con un amigo o familiar atendiendolo) y 879 RS

($11.63) (con un trabajador sanitario). En una unidad sanitaria, el precio promedio de un parto normal era de 678 RS ($8.97). Cuando se anadıan

cargos adicionales, costos de oportunidad y transporte, el total excedıa los 5,300 RS ($70). Para una cesarea, los costes familiares totales eran de mas de

11,400 RS ($150). Basandose en estos numeros, el costo de financiar las practicas actuales es de 45 RS ($0.60) per capita. Una polıtica institucional

universal de partos costarıa 238 RS ($3.15) per capita, mientras que una polıtica de atencion domiciliaria cualificada con transferencia temprana de

casos en areas remotas costarıa alrededor de 117 RS ($1.55) per capita. Estos son numeros significativos en el contexto de un presupuesto sanitario de

aproximadamente ($5) per capita.

conclusiones El costo financiero de desarrollar una estrategia de atencion cualificada en Nepal es sustancial. Deben mejorarse los mecanismos para

dirigir los fondos hacia las mujeres que lo necesitan; la polıtica tarifaria tendrıa que ser mas transparente; y las exenciones en los pagos en los centros

publicos tendrıan que estar mejor financiados si se han de superar tanto las barreras de oferta como de demanda en la busqueda de ayuda sanitaria.

palabras clave maternidad segura, atencion cualificada, costos, financiamiento




financial implications of skilled attendance at delivery in nepal

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