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Ghana's Free Delivery Care Policy.

Developing countries continue to bear the larger portion of pregnancy-related deaths. It is recognised that access to skilled delivery care of good quality will contribute to reducing maternal and perinatal mortality and morbidity. The importance of this situation is reflected in the Millennium Development Goal (MDG) 5 aimed at reducing maternal mortality ratios by 75% by the year 2015. 
 
In Ghana, maternal mortality ratio is estimated to range from 214 to 700 per 100,000 live births1. These figures have persisted for some time despite various policies and initiatives including an Antenatal Care policy and the Safe Motherhood initiative. 
 
In September 2003, the Ministry of Health of Ghana introduced an exemption policy directed at making delivery care free. The thrust of these policies have been to improve uptake, quality and financial and geographic access to delivery care services. The services covered by the exemption policy are normal deliveries, assisted deliveries including Caesarean section and management of medical and surgical complications arising out of deliveries, including the repair of vesico-vaginal and recto-vaginal fistulae2. The policy covered delivery services in public, private and faith-based health facilities. 
 
In this issue we publish articles resulting from an evaluation of Ghana's free delivery care policy3 carried out under the auspices of the Initiative for Maternal Mortality Programme Assessment (Immpact)4 and other reports on obstetric care. We also carry commentaries on the social dimensions of the policy and the effect of the policy on service delivery and quality of care. 
 
The evaluation carried out by Immpact looked at the effects of the free delivery policy on utilization and quality of delivery services, delivery outcomes and the economic consequences for households. 
 
Generally, while the policy was considered favourably by both service providers and users there were significant problems with its implementation. The implementation of the policy did not have adequate financial backing and a system of standardised charging was not applied. Failure of prompt and adequate reimbursement to the clinical facilities led to near failure of the policy5. Many facilities at one point reverted to collection of user fees. The policy was more beneficial to the rich than to the poor. The evaluation clearly showed that quality of clinical care was consistently poor and was not affected by the implementation of the exemption policy. Other barriers to skilled delivery care identified included costs of transportation, medicines and other supplies, long distances to health facilities, cultural and social barriers and preference for services of Traditional Birth Attendant (TBA). An effective monitoring system was not put in place and therefore many of the deficiencies in financial flows, quality of care and issues related to poverty were not documented before the Immpact evaluation. 
 
This evaluation has lessons for future policies and strategies in reducing perinatal and maternal morbidity and mortality. These include behaviour change strategies for providers and users, improving clinical quality of care and provider competencies, ensuring availability of funds to cover the exemptions, creating an enabling environment to address cultural barriers, identifying ways to improve the imbalance between the rich and the poor and strengthen the culture of performing policy analysis. 
 
 
 
 
Professor David Ofori-Adjei 
 
 
 
Editor-in Chief, Ghana Medical Journal