title: Delivery fee exemption and subsidy policies: how have they affected health staff? Findings from a four-country evaluation.
abstract: Many countries, especially in Africa, have in recent years introduced fee exemptions or subsidies targeting deliveries and emergency obstetric care. A number of aspects of these policies have been studied but there are few studies which look at how staff have been affected and how they have responded. This article focuses on this question, comparing data from Benin, Burkina Faso, Mali and Morocco. It is nested in wider evaluation of the policies. The article analyses responses to a health worker survey, carried out in 2012 on 683 health staff (doctors, nurses, midwives and others such as auxiliaries) across the four countries. The survey focused on working hours, workloads, pay, motivation and perceptions of the policies, as well as reported changes in workload and remuneration over the period of policy introduction. Self-reported staff output ratios suggest that midwives are over-worked across all settings, but facility data presents lower estimates, making it hard to judge the adequacy of workforces. Staff are generally positive about the policies’ effects on the health system (increasing supervised delivery rates, benefiting the poor, improving access to medicines and supplies and improving quality of care). In personal terms, staff in Mali and Burkina Faso report increased satisfaction with work as a result of the policies, while in Benin, there is little change and in Morocco a deterioration (which correlated with recommendations about extending exemption policies in future). Awareness of policies was high amongst staff but only a small minority had received any written guides or training on policy implementation. It is crucial that planned health financing changes engage with their implications for staffing—estimating whether specific cadres can absorb increase demand, for example, as well as how to engage them in the policy implementation such that their personal needs are met and their professionalism enhanced.
authors.affiliation: Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK.
authors.forename: Sophie
authors.initials: S
authors.lastname: Witter
authors.affiliation: Public Health Department, Centre MURAZ, Bobo-Dioulasso, Burkina Faso.
authors.forename: Patrick G
authors.initials: PG
authors.lastname: Ilboudo
authors.affiliation: Immpact, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.
authors.forename: Nadia
authors.initials: N
authors.lastname: Cunden
authors.affiliation: Ecole Nationale de Santé Publique, Rabat, Morocco.
authors.forename: Chakib
authors.initials: C
authors.lastname: Boukhalfa
authors.affiliation: Centre de Recherche en Reproduction Humaine et en Démographie, Cotonou, Benin.
authors.forename: Patrick
authors.initials: P
authors.lastname: Makoutode
authors.affiliation: Marikani, Bamako, Mali.
authors.forename: Zoumana
authors.initials: Z
authors.lastname: Daou
mesh_terms: D000293:Adolescent; D000328:Adult; D000349:Africa; D000368:Aged; D002585:Cesarean Section / Q000191:economics; D036861:Delivery, Obstetric / Q000191:economics*; D005260:Female; D006282:Health Personnel / Q000191:economics* / Q000523:psychology; D006291:Health Policy / Q000191:economics*; D006280:Health Workforce / Q000191:economics; D006801:Humans; D007588:Job Satisfaction; D008297:Male; D008875:Middle Aged; D009042:Motivation; D009774:Obstetrics; D011795:Surveys and Questionnaires; D016526:Workload