Evaluating the economic outcomes of the policy of fee exemption for maternal delivery care in Ghana

SUMMARY BACKGROUND: The Government of Ghana's fee exemption policy for delivery care introduced in September 2003, aimed at reducing financial barriers to using maternal services. This policy also aimed to increase the rate of skilled attendance at delivery, reduce maternal and perinatal mortality rates and contribute to reducing poverty. OBJECTIVE: To evaluate the economic outcomes of the policy on households in Ghana. METHODS: Central and Volta regions were selected for the study. In each region, six districts were selected. A two stage sampling approach was used to identify women for a household cost survey. A sample of 1500 women in Volta region (made up of 750 women each before and after the exemption policy) and 750 women after the policy was introduced in Central region. OUTCOME MEASURES: Household out-of-pocket payment for maternal delivery and catastrophic out-of-pocket health payments. RESULTS: There was a statistically significant decrease in the mean out-of-pocket payments for caesarean section (CS) and normal delivery at health facilities after the introduction of the policy. The percentage decrease was highest for CS at 28.40% followed by normal delivery at 25.80%. The incidence of catastrophic out-of-pocket payments also fell. At lower thresholds, the incidence of catastrophic delivery payment was concentrated more amongst the poor. For the poorest group (1(st) quintile) household out-of-pocket payments in excess of 2.5% of their pre-payment income dropped from 54.54% of the households to 46.38% after the exemption policy. The policy had a more positive impact on the extreme poor than the poor. The richest households (5(th) quintile) had a decline in out-of-pocket payments of 21.51% while the poor households (1(st) quintile) had a 13.18% decline. CONCLUSIONS: The policy was beneficial to users of the service. However, the rich benefited more than the poor. There is need for proper targeting to identify the poorest of the poor before policies are implemented to ensure maximum benefit by the target group.