title: Matching comprehensive health insurance reimbursements to their real costs: the case of antenatal care visits in a region of Peru.
abstract: BACKGROUND
  Prepaid contributory systems are increasingly being recognized as key mechanisms in achieving universal health coverage in low and middle-income countries. Peru created the Seguro Integral de Salud (SIS) to increase health service use amongst the poor by removing financial barriers. The SIS transfers funds on a fee-for-service basis to the regional health offices to cover recurrent cost (excluding salaries) of pre-specified packages of interventions. We aim to estimate the full cost of antenatal care (ANC) provision in the Ventanilla District (Callao-Peru) and to compare the actual cost to the reimbursement rates provided by SIS.
  
  
  METHODS
  The economic costs of ANC provision in 2011 in 8 of the 15 health centres in Ventanilla District were estimated from a provider perspective and the actual costs of those services covered by the SIS fee of $3.8 for each ANC visit were calculated. A combination of step-down and bottom-up costing methodologies was used. Sensitivity analysis was conducted to test the uncertainty around estimated parameters and model assumptions. Results are reported in 2011 US$.
  
  
  RESULTS
  The total economic cost of ANC provision in all 8 health centres was $569,933 with an average cost per ANC visit of $31.3 (95 % CI $29.7-$33.5). Salaries comprised 74.4 % of the total cost. The average cost of the services covered by the SIS fee was $3.4 (95 % CI $3.0-$3.8) per ANC visit. Sensitivity analysis showed that the probability of the cost of an ANC visit being above the SIS reimbursed fee is 1.4 %.
  
  
  CONCLUSIONS
  Our analysis suggests that the fee reimbursed by the SIS will cover the cost that it supposed to cover. However, there are significant threats to medium and longer term sustainability of this system as fee transfers represent a small fraction of the total cost of providing ANC. Increasing ANC coverage requires the other funding sources of the Regional Health Office (DIRESA) to adapt to increasing demand.
authors.affiliation: Swiss Tropical and Public Health Institute, Basel, Switzerland ; University of Basel, Basel, Switzerland.
authors.forename: Daniel
authors.initials: D
authors.lastname: Cobos Muñoz
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Kristian Schultz
authors.initials: KS
authors.lastname: Hansen
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Fern
authors.initials: F
authors.lastname: Terris-Prestholt
authors.affiliation: Department of Public Health, HSE Carlow/Kilkenny, Lacken, Kilkenny, Ireland.
authors.forename: Fiona
authors.initials: F
authors.lastname: Cianci
authors.affiliation: School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru.
authors.forename: José Enrique
authors.initials: JE
authors.lastname: Pérez-Lu
authors.affiliation: Regional Health Directorate of Callao, Regional Government of Callao, Callao, Peru.
authors.forename: Aldo
authors.initials: A
authors.lastname: Lama
authors.affiliation: School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru.
authors.forename: Patricia J
authors.initials: PJ
authors.lastname: García
keywords: Antenatal care; Cost; Social health insurance; Sustainability