Removing financial barriers to access reproductive, maternal and newborn health services: the challenges and policy implications for Human Resources for Health (HRH)
Barbara McPake, Sophie Witter, Tim
Ensor, Suzanne Fustukian, David
Newlands, Tim Martineau

• Growing consensus that user fees are regressive; undermine equitable access to health services; constrain improved health for pregnant women and children under five
• Many low and middle income countries reconsidering levying user charges: reinforcing exemption mechanisms, significant reduction in fee levels or abolition altogether
• Consequences for the health system: search for replacement revenue; response to changes in utilization
• Specific concerns for human resources for health
• Demand side support requires balance with supply side support

The objective of this research was:
To explore the associations and interrelationships between workforce characteristics (stock, distribution, competencies and motivational state) and equitable access to
Reproductive Maternal and Newborn Health
(RMNH) services resulting from the removal of, or exemption from user fees.

Research questions
In priority countries, what is the evidence on the impact of
– fees, exemptions and fee removal on HRH;
– and of HRH characteristics on the impact of fees, exemptions and fee removal?

In each of Sierra Leone, Zimbabwe, Zambia,
Nepal and Ghana and where possible, before and after a change in user fee policy:
• What is the distribution and skill mix of the
RMNH workforce?
• What is the workload managed by the RMNH workforce
• What data are available about the remuneration and terms and conditions
(including deployment procedures)

• What are the projected needs for RMNH workforce given standard estimates of capacity per FTE by cadre?
• What plans are in place to improve RMNH workforce capacity both quantitatively, qualitatively and with respect to geographical distribution?
• What formal fees exist for RMNH services?
• Where are revenues from formal fees retained and how are they used?

• What exemption policies exist and how are they applied?
• What evidence is available of the demand suppression effect of formal fees?
• What are the policy implications of the evidence from questions (i) to (viii)?

• Literature review (not included in presentation)
• Desk based data analysis and document review
• Field studies in Sierra Leone and Zimbabwe

• Exemptions introduced for delivery care 2004 first in 5 regions, then across country
• Policy later superseded in 2008 by free coverage of all pregnant women within National Health
Insurance Scheme (NHIS)
• Both policies undermined by poor availability of funds
• Government HRH policy focused on task shifting and improving distribution including deprived area incentives scheme
• Large pay increases 2006
• 2006-7: significant expansion of training schools

• In principle, all citizens have free access to primary care
• Targeted groups also protected from secondary care costs
• Policies undermined by shortfalls in funding
• 2008 Aama policy: free institutional deliveries in all public and some private facilities
• 2005: financial incentives for women to delivery in a facility
• Target of 71% increase in public sector workforce by 2017 – emphasis on SBA competent health providers

• Free Health Care Policy – free public care for pregnant and lactating women and children under 5, April 2010
• Substantial salary increases, 2011
• Performance based financing system being introduced 2011
• HRH policy plans incentives for hard-to-reach areas and reformed career paths and recruitment processes

• User fees abolished for rural primary care in
2006, peri-urban areas 2007; government and mission facilities
• Compensation for loss of revenue through DFID grant
• HRH policies – training and recruitment of graduates; developing HR information systems, scaling up of Zambia Health Workers Retention
Scheme offering salary top-ups in remote areas

• Policy of free care but inconsistently applied
• Perception that charging can be locally determined
• Dollarization of economy may have increased real value of fees
• HRH expenditure collapsed to 0.3% of public health budget in 2008
• Emergency Retention Scheme introduced, but to be phased out by 2013
• HRH strategic plan: retention of staff key priority

Effects of user fee policy change on utilisation
• Ghana: delivery exemption modest gains in utilisation and equity; increased in use of formal care for members of NHIS but not maternal care; increased use of OPD in population since NHIS introduction
• Nepal: utilisation rates of disadvantaged groups improving and substantial increase in facility births since Aama

• Sierra Leone: impact of FHCP mixed; immediate increase in OPD use but decline since; falling immunisation rates; increases in maternal health service use
• Zambia: increased OPD utilisation for adults but not consistent across districts and some evidence of crowding out of under 5s who previously received free care.
• Zimbabwe: no discrete financing policy change

Distribution of health workforce by
0,4
0,3
0,6
0,5
0,8
0,7
0,2
0,1
0
Ghana (2011) cadre
All doctors
All nurses
All midwives
All clinical officers
All ANMs
Nepal (2011) Sierra Leone (2007) Zambia (2010) Zimbabwe (2010)

0,3
0,2
0,1
0
0,7
0,6
0,5
0,4
0,8
0,9
Distribution of health workforce by sector
Public sector
Private sector
NGO/FBO sector
Ghana (2011) Nepal (2011) Sierra Leone (2007; nurses only)

Delivery workload for skilled birth attendants and doctors: actual rate of facility based deliveries and full coverage (all births)
Ghana 2010/11
Births per
SBA
29
Births per doctor
283
Deliveries per SBA
13
Deliveries per doctor
127
Nepal 2011 309 525 132 224
Sierra Leone
Zambia Narrow
1202
185
Zambia Broad 133
1048
1317
320
73
52
279
515
Zimbabwe 18 475 12 313

Public sector remuneration (salary midpoints incorporating allowances) in international dollars and as a ratio to GNI per capita (all current: December
2011)
Value of salary and allowances in Int$
Doctor ∆ Nurse Midwife
Salary expressed as ratio to p.c.
GNI
Doctor Nurse Midwife
Ghana 3932
Nepal 4408
Sierra
Leone 3179
2171
3851
429®
2171
578°
28.4
43.7
46.0
15.7
38.2
6.2®
15.7
8.4°
Zambia 5346
Zimbabw e*
218
2167
176
46.5
4.4
18.4
3.6

Assumptions and results for staff requirements for scaling up skilled birth attendance in Nepal, Sierra Leone and Zambia
Doctors Skilled birth attendants
Common assumptions
Deliveries/year
Salary growth
Nepal
Attrition
Baseline salary (current
US$)
1000
3%
5%
3972
Scale-up needed 43-95%
Additional staff needed 0
175
3%
5%
3468
Annual cost in
2015(current US$)
6,003,621
3456 (109% increase)
17,661,052

Sierra Leone
Attrition
Baseline salary
(current US$)
Additional staff needed
Scale-up needed
Annual cost (current
US$)
Zambia
Attrition
Baseline salary
(current US$)
Scale-up needed
Additional staff needed
Annual cost (current
US$)
5%
1,847
21 (9% increase)
44-95%
374,352
5%
18,246
12,693,524
5%
679
1212 (515% increase)
896,024
10%
8,581
47%-95%
382 (29% increase) 2464 (47% increase)
35,527,457

Conclusions
• Is there an HRH crisis?
– Situations quite varied
– Shortages mainly driven by poor internal distribution
• Health workers are relatively well paid with some exceptions
• Shortages of SBA staff matched by questions about the competence of those counted
Utilisation impacts of user fee removal variable – case studies confirm importance of supporting supply side
• Some effort to co-ordinate HRH and financing polices with mixed success
• Data gaps huge