Mortality rates in Guinea have dropped significantly over the past two decades, but efforts to speed up progress on the Millennium Development Goal (MDG) to reduce maternal mortality by three-quarters by 2015 through a ban on childbirth fees, including for Caesarean sections, are stalling due to poor planning and lack of resources, say critics.
No sustainable costing plan has been put in place to cover the fees. A health insurance scheme has been set up, but functions on a very small scale.
“You can’t just say something is free - you have to plan. Making maternal delivery free burdens health structures, which have not been given enough new money to cover it… for the most part delivery is free now, but the money will soon run out and they will have to find new sources,” the National director of community health and disease prevention, Hawa Touré, told IRIN.
In Guinea, 680 women die out of 100,000 live births, down from 1,200 in 1990, according to the UN.
Health not prioritized
In 2010 just 2.5 percent of the annual national budget was allocated to the Ministry of Health, according to the Health and Public Hygiene Minister, Naman Kéita. This rose to between 4 and 5 percent in 2011 - a marked improvement - but still far lower than the goal of 15 percent set in the Abuja Declaration.
As a result, the bulk of the health budget is covered by donors such as the Global Fund, GAVI, which promotes vaccination, the World Bank and the World Health Organization; and individual donors such as France, Japan and Spain.
Abolishing user fees works when there is a plan in place to boost the number of medical staff and equipment available to address expected higher demand; and a financial strategy to cover the care costs, according to lessons learned from similar schemes in Sierra Leone, Burundi and Mozambique.
Fatou Sikhé Camara, Director General of Guinea’s largest public hospital, Donka, in the capital Conakry, told IRIN the government had given the hospital a subsidy to cover costs, but she could not specify the amount, or how it had been used.
Asha Camara, 21, said she stayed overnight at the hospital but had not paid to give birth. “I paid for food - not much else,” she told IRIN on leaving Donka with her newborn baby.
The scheme would have more impact on maternal mortality if ante-natal and post-natal care visits were also covered, said Julien Harneis head of the UN Children’s Fund (UNICEF) in Guinea. “The approach is too medicalised - covering ante-natal consultations would identify at-risk women and highlight in advance those who require more assistance.”
Ifonou Estelle Montserey, who is eight months pregnant, waited for her prescription on a bench outside the ante-natal unit at Donka Hospital. She showed IRIN separate bills of US$10 for her monthly scan and a $3 consultation fee. “Last month I paid $7.40 [for the scan]. Nothing is consistent here… and nothing is free in Guinea.”
The effect of the fee abolishment is as yet unknown: a countrywide district health survey addressing maternal mortality rates, among other issues, is underway and the results will be published in 2012.
But a prominent development specialist told IRIN she expected the strategy to have little added impact, given the way it’s been delivered. “On the plus side, it’s good that the government proposed it, but they now need to finance it,” she said.
Minister Kéita told IRIN he hopes the health budget will be increased in 2012, and if it is the government will set aside funds to finance the plan. “Maternal mortality is one of our priority areas. But we lack resources. We need more personnel, more money, and more equipment to make this work.”
The number of medical staff per capita remains very low in Guinea: 401 midwives are thought to be practicing in the country, according to the UN Population Fund. To reach the MDG target of 95 percent of births covered by a skilled birth attendant, a further 2,294 personnel are needed.
Kéita said the government had launched a drive to recruit some 1,800 midwives and nurses earlier this year, the first such campaign in five years. According to UNFPA there is just one private school with a three-year midwifery programme.
Funding is often drained through widespread corruption according to medical staff at Donka.
“Maternal mortality needs more work, here,” said Harneis. “Progress on reducing maternal mortality is taking too long. Donors and the government need to come up with a joint vision to fight it… we are not where we need to be.”
Acknowledging the challenge, he noted that “You can’t vaccinate against all the risks associated with pregnancy - while polio or measles can be tackled with once-a-year campaigns, the response to maternal mortality is oriented around the quality of the healthcare structure, which in Guinea is consistently poor.”