THE PRICE TO PAY FOR MATERNAL HEALTH CARE IN RURAL GAMBIA Laila Iren Løchting Supervisor: Professor Johanne Sundby, MD, PHD Co-supervisor: Elizabeth Nygaard, Cand. Oecon University of Oslo Faculty of Medicine Department of General Practice and Community Medicine Section for International Health May 2008 Thesis submitted as a part of the Master of Philosophy Degree in International Community Health TABLE OF CONTENT ABSTRACT…………………………………………………………………………………………....5 ABBREVIATIONS……………………………………………………………………………………..7 ACKNOWLEDGMENTS……………………………………………………………………………...8 1.0 INTRODUCTION ............................................................................................................. 9 1.1 INTRODUCTION .............................................................................................................. 9 1.2 DESCRIPTION OF THE CONTEXT .....................................................................................10 1.2.1 Profile of the Gambia: ..........................................................................................10 1.2.1.2 Geography ....................................................................................................10 1.2.1.3 Demographics: ..............................................................................................11 1.2.1.4 Health status of the population ......................................................................12 1.2.1.5 Political situation ...........................................................................................13 1.2.1.6 Economy .......................................................................................................13 1.2.3 Poverty in the Gambia .........................................................................................15 1.2.4 Women in the Gambia .........................................................................................16 1.3 HEALTH POLICIES AND STRATEGIES .....................................................................18 1.3.1 National Health Policies .......................................................................................18 1.3.1.1 National Reproductive Health policy: .............................................................19 1.4 HEALTH CARE DELIVERY SYSTEM ...................................................................................19 1.4.1 Primary level ........................................................................................................20 1.4.2 Secondary and tertiary level .................................................................................20 1.4.3 Human Resources ...............................................................................................20 1.4.4 Maternal health services ......................................................................................21 1.4.4.1 Traditional Birth Attendants: ..........................................................................22 1.5 HEALTH CARE FINANCING ..............................................................................................22 1.5.1 Drug Revolving Fund ...........................................................................................23 1.5.1.1 Bamako Initiative ...........................................................................................23 1.5.1.2 Exemption system .........................................................................................24 1.5.1.3 Household spending for health. .....................................................................24 2.0 BACKGROUND ..............................................................................................................25 2.1 ACCESS TO HEALTH CARE ......................................................................................25 2.1.1 Measuring accessibility and equity .......................................................................25 2.1.2 Access to health care in the Gambia ....................................................................26 2.1.2.1 Access to maternity care in the Gambia ........................................................27 2.2 REVIEW OF THE LITERATURE .................................................................................28 2.2.1 Supply and demand of health care .......................................................................28 2.2.2 User cost .............................................................................................................28 2.2.3 Cost as a barrier to health care ............................................................................30 2.2.3.1 Willingness and ability to pay ........................................................................31 2.2.3.2 Coping mechanisms ......................................................................................32 3.0 AIM OF THE STUDY ......................................................................................................33 3.1 RATIONALE FOR THE STUDY ..................................................................................33 3.2 PURPOSE OF THE STUDY ........................................................................................34 3.3 OBJECTIVES OF THE STUDY ...................................................................................34 3.4 STUDY AREA .............................................................................................................34 3.4.1 Maternal health services in URD and CRD ..........................................................35 4.0. METHODOLOGY ..........................................................................................................36 4.1 STUDY DESIGN .........................................................................................................36 4.2 STUDY POPULATION ................................................................................................36 4.3 SAMPLE SIZE ............................................................................................................36 4.4 SAMPLE SELECTION ................................................................................................37 4.5 DATA COLLECTION TOOLS ......................................................................................38 4.5.1. Pre testing of the questionnaire ...........................................................................38 2 4. 6 DATA COLLECTION PROCEDURE ..........................................................................39 4.6.1 Research assistants: ............................................................................................39 4.7 DATA HANDLING .......................................................................................................40 4.8 DATA ANALYSIS ........................................................................................................40 4.9 ETHICAL CONSIDERATIONS ....................................................................................40 4.10 LIMITATIONS AND CHALLENGES ..........................................................................41 4.10.1 Validity ...............................................................................................................42 4.10.2 Reliability ...........................................................................................................43 5.0 RESULTS .......................................................................................................................43 5.1 DESCRIPTION OF THE TOTAL STUDY SAMPLE ......................................................43 5.2 ESTIMATION OF THE TOTAL HOUSEHOLD COST FOR HEALTH FACILITY DELIVERIES ....................................................................................................................45 5.2.1. Health facility cost ...............................................................................................45 5.2.2 Transport costs ....................................................................................................47 5.2.3 Proportion of health facility costs on general consumption expenditure................48 5.3 THE EXTENT OF WHICH HOUSEHOLDS OPT OUT OF INSTITUTIONAL DELIVERIES DUE TO HIGH COST ..................................................................................50 5.3.1 Reasons for home delivery ..................................................................................51 5.3.1.1 Expectations of cost ......................................................................................52 5.3.1.2 Affordability and Reasonability ......................................................................52 5.3.1.3 Preferred place of delivery ............................................................................52 5.3.2 Prioritization and willingness to pay .....................................................................53 5.4 CHARACTERISTICS OF THE HOUSEHOLD THAT OPTED OUT OF PUBLIC DELIVERY SERVICES DUE TO COST ............................................................................54 5.4.1 Risk factors for not using the health facility for the delivery ..................................55 5.5 FINANCIAL STRATEGIES OF HOUSEHOLD TO COPE WITH HEALTH EMERGENCIES ...............................................................................................................57 6.0 INTERPRETATION OF FINDINGS ................................................................................59 6.1 HOUSEHOLD COSTS ................................................................................................59 6.1.1 Total cost .............................................................................................................60