Bulletin of the World Health Organization

March 2013: Expectant mothers in Mali risk financial ruin; systems problems impede universal health coverage

NOTICE TO READERS: The Bulletin of the World Health Organization was created by WHO as a forum for public health experts to publish their findings, express their views and engage a wider audience on critical public health issues of the day. Consequently, the views expressed by the writers in these pages do not necessarily represent the views of WHO.

Note for the Media

Families in Mali risk financial ruin when expectant mothers need a Caesarean section to guarantee safe delivery, despite recent measures to make this life-saving procedure accessible and free at point-of-care, according to a study published this month in the Bulletin of the World Health Organization.

Mali’s experience is relevant to the many countries that are drawing up plans to make essential health services, including Caesareans, more widely available to their people as part of broader efforts to achieve universal coverage.

Universal health coverage means that all people can use the health services they need while being protected against the financial hardship often associated with paying for them. In 2011, WHO’s Member States set themselves the goal of developing their health financing systems as the basis for universal health coverage, but progress is patchy.

Mali has traditionally had one of the world’s highest rates of death among women due to pregnancy and childbirth. To address this, Mali set up a national system in 2002 under which expectant women in need are referred to the nearest hospital for a Caesarean or other emergency obstetric care.

Within a couple of years, the number of women receiving emergency obstetric care had doubled, according to an earlier study in the Kayes region of 1.9 million people, where 475 women received such care one year before the system was introduced compared to 913 two years after its introduction.

But Mali’s success in reducing the risk of maternal death has been marred by the fact that, despite abolition of point-of-care fees for Caesareans in 2005, families who seek them still risk financial ruin. The study, which was published this month, was based on data collected between 2008 and 2011. It showed that families had to pay an average of US$ 152 each time a woman was taken to hospital for the management of an obstetric complication including Caesareans, a quarter of the annual per capita income of US$ 600 in this sub-Saharan country.

“We found that 44.6% of the families who incurred these high costs were, as a result, forced to reduce their food consumption, while 23.2% of them were still in debt 10 months to two and a half years after the birth,” said co-author Pierre Fournier, director of the Global Health Center at the University of Montreal in Canada.

Co-author Catherine Arsenault added that the reason for these expenses were the high cost of medicines, which were not included in the government-provided Caesarean kits, and the cost of emergency transport. “While these efforts are commendable, the government also needs to ensure that the system is adequately funded so that people do not risk financial ruin,” Arsenault said.

Millions of people all over the world suffer because they cannot access the health-care services they need, or because paying for these pushes them into poverty. According to Riku Elovainio, a health economist at the World Health Organization (WHO), the study has important lessons for countries trying to protect their people from financial hardship.

“A fee-exemption policy is an important strategy for making health care more accessible, but this needs to be funded and organized properly, otherwise patients must fill the financing gap themselves which can plunge them into poverty,” Elovainio said. “Countries will not be able to move effectively towards their goal of universal health coverage unless they tackle problems such as these in their health systems.”

WHO is working with countries to review, develop and implement health financing strategies that help countries to move closer towards universal health coverage through evidence based actions and reforms.

Also in this month’s issue:

  • A global elimination target for congenital syphilis?
  • Losing limbs and lives to landmines
  • Rapid roll out of new tuberculosis test in South Africa
  • Interview: Brazil and the yellow fever vaccine
  • Tracking the effects of new vaccines
  • Making medicines affordable in China
  • Impact of WHO HIV/tuberculosis treatment guidelines in Cambodia

The Bulletin of the World Health Organization is one of the world’s leading public health journals. It is the flagship periodical of WHO, with a special focus on developing countries. Articles are peer-reviewed and are independent of WHO guidelines. Abstracts are now available in the six official languages of the United Nations.

The March issue table of contents can be found at: http://www.who.int/bulletin/volumes/91/3/en/index.html

The complete contents of the Bulletin, since 1948, is available free to all readers worldwide through PubMed Central, available at: http://www.pubmedcentral.nih.gov/tocrender.fcgi?journal=522&action=archive

For further information please contact:

Fiona Fleck
News Editor
Bulletin of the World Health Organization
Geneva, Switzerland
Office: +41 22 791 1897
Email: fleckf@who.int

Dr Pierre Fournier
Director of the Global Health Center
Research Center of the University of Montreal Hospital
Montreal, Canada
Office : +1 890 8000 ext 15926
E-mail: pierre.fournier@umontreal.ca

Catherine Arsenault
Research Center of the University of Montreal Hospital
Montreal, Canada
Office: +1 890 8000 ext 15957
Mobile: +1 514 567 0286
E-mail: catherine.arsenault@umontreal.ca

Dr Riku Elovainio
Technical Officer
Department of Health Systems Financing
World Health Organization
Geneva, Switzerland
Office: +41 22 791 2028
E-mail: elovainior@who.int