Scrapping user fees bears fruits

Paidamoyo Chipunza Senior Health Reporter
July 1, 2012 marked a turning point for Zimbabwe’s rate of women and children who die due to pregnancy or related complications as Government scrapped user fees in all its clinics in rural areas.

The rate of women who die due to pregnancy and related complications in Zimbabwe had shot up to an average of eight up from an average of three women in the 1990s – a trend that was in contrast to the country’s global targets of improving maternal health and reducing child mortality (Millennium Development Goals 5 and 4). Through the Health Transition Fund (HTF), a pool of donor funding, Government sought to raise $435 million over a period of five years, which was to be used in reimbursing health facilities for services offered free of charge.

Although this maternal and child health user fee policy had its pitfalls, to date all Government rural health institutions and some council institutions have taken heed of the directive to scrap costs.

Manicaland provincial medical director Dr Patron Mafaune who confirmed this development in her province said the policy was bearing fruit as evidenced by the increased number of institutional deliveries.

“Services have actually improved for the maternal mothers in clinics which are the primary level of care,” said Dr Mafaune.

She however said the challenge is with the secondary level of care institutions that are not funded by either HTF or any other form of financing as they have no cost recovery for services rendered to expecting mothers.

“This compromises the quality of care at these institutions as resources are then not available or inadequate to manage the referred mothers from the well-resourced lower levels,” she said.

Dr Mafaune challenged Government to ensure that there was adequate cost recovery for all institutions.

She said in addition to scrapping of maternal user fees, there was need to consider issues of geographical location of health institutions in the country and road networks in a bid to bring the services closer to the people.

“There are still religious objectors with mothers being assisted to deliver by traditional birth attendants of their religious sects. Unfortunately in these traditional homes complications cannot be identified leading to more mothers dying,” she said.

The scenario in Manicaland is almost similar to Masvingo province where all Government institutions have taken heed to the call to offer maternal and child health services free of charge. The province’s medical director, Dr Robert Mudyiradima however said some council clinics where still charging user fees for both pregnant women and children under five years. He said Government needs to ensure timely disbursements of recovery costs for a smooth implementation of the user fee policy in all institutions. Dr Mudyiradima said failure to disburse funding timely impacted negatively on service provision as facilities fail to procure medical sundries required in delivery wards, medicines, x-rays, blood, detergents and food for the mothers. The disbursements for cost recovery are supposed to be done on a quarterly basis but they were last done in the first quarter of April 2014.

“Government needs to keep its end of the bargain by compensating the agreed amount for each delivery, the money needs to come in the agreed timeframe that is quarterly,” said Dr Mudyiradima.

He added that there was need to ensure adequate provision of tools of the trade such as foetal heart dopplers, training of nurses in maternity skills, increase establishment of nurses and doctors in rural health centres to effectively reduce the numbers of women who die while giving birth. Mrs Rosemary Makonese of Murehwa applauded Government’s policy on free maternal services saying it made maternal services accessible to many women.

“We all know that things are getting difficult by each day in the country and raising money for registration is a woman’s nightmare,” she said.

She said often women ended up delivering in their homes as they fail to raise money for registering to deliver in a health institution.

“Because registering and delivering are done separately, women ended up ignoring registering their pregnancies and wait to deliver from their homes,” she said.

Community Working Group on Health executive director Mr Itai Rusike whose organisation is involved in community health programmes said while majority of rural health centres were no longer charging maternal user fees as a result of support from the funding mechanisms in place such as the HTF, disadvantaged women in urban areas still had to pay user fees of up to US$25 to register at clinics and about US$50 at hospitals.

“We therefore have seen a sizeable number of urban poor pregnant women going to deliver at their rural homes to avoid paying fees or even delivering at home thereby increasing the risk of complications or even death,” he said.

Mr Rusike said while Government ordered all its institutions to scrap user fees as a policy, the policy is not backed by any Statutory Instrument to compel all institutions to let women deliver for free.

“It is just a Ministry of Health policy more or less, like a gentleman’s agreement that makes it very difficult to enforce as it can be easily ignored by local authorities and mission hospitals who own the majority of the clinics in Zimbabwe,” he said.

Health and Child Care Secretary Dr Gerald Gwinji acknowledged that the user fee policy for maternal and child health had been easier to implement at lower levels of care and has met some challenges at the higher levels.

“The reasons are that someone has to eventually pay for a service even if it is received for free by a user,” Dr Gwinji said.

He said at the lower level of care different partners had been assisting with financial resources through the HTF and the Results Based Financing- administered by the World Bank. Dr Gwinji said the same has not happened at higher levels of care and in urban areas.

“Removing user fees removes a barrier to service and allows access and utilisation. This then works with other factors such as quality of care to contribute towards reduction in mortality,” Dr Gwinji said.

He said the HTF was one of the many Government interventions that contributed to improving maternal health and reducing the number of infant mortality.

Latest statistics from the Multiple Indicator Cluster Survey (2014) showed a decline in the number of women who die during child birth to 614 deaths per 100 000 live births. The country’s national census conducted over a short period of time in 2012 showed an even lower rate of 581 deaths per 100 000 live births.

“The trends are indeed encouraging. What we need to do is to work on issues of improving that trend.

“Although significant progress has been made to achieve some of the MDGs indicators, not all will be met,” said Dr Gwinji.

Zimbabwe’s target, according to the MDGs, was to reduce the number of women who die while giving birth to 174 deaths for every 100 000 live births.