Answering the millennium call for the right to maternal health: the need to eliminate user fees.

• Author: Hall, Margaux J.

INTRODUCTION

Complications during childbirth and pregnancy are one of the main sources of death and disability among women of reproductive age in developing countries. (1) Approximately 536,000 women died from pregnancy-related complications in 2005. (2) For every woman who dies, about twenty others suffer serious injury, infection, or disease. (3) The majority of maternal deaths are preventable, even in countries with limited resources. (4) Behind these startling statistics are the individual stories of persons whose lives are dramatically altered as a result of maternal death--the story, for example, of a young Nigerian woman who went into premature labor as a result of preeclampsia and needed an emergency caesarian section, (5) Her husband learned that the procedure would cost 20,000 naira (about $160) and abandoned his wife, leaving her friends and relatives to try to raise the money. (6) When the doctors refused to perform the required surgery until her family raised 70% of the money, she died. (7)

In the background of the stories are other deeply affected persons children who suffer from the disappearance of a key caretaker, and spouses, partners, and extended family members who must stretch their resources and assume responsibility for child-rearing and other roles formerly filled by the mother. Maternal deaths do not affect just one person; they impact whole families and communities.

The problem of maternal deaths is experienced most profoundly in developing countries, which account for 99% of the total annual maternal deaths, 533,000 worldwide in 2005. (8) Africa and South Asia together combined to make up 86% of total worldwide maternal deaths in 2005. (9) Significant differences also exist within nations, with poor and rural areas frequently experiencing more maternal deaths than their wealthier and urban counterparts. (10)

The world's nations, by endorsing the United Nations Millennium Development Goals (MDGs) and other international development consensus documents, have recognized that most of women's deaths and injuries due to pregnancy-related health complications are preventable. They have pledged to take urgent action to ensure that maternal mortality is reduced by 75% by 2015. (11) To meet this goal, all women must have access to high-quality health care services during child delivery. (12) The MDGs list three essential elements of these services: a skilled attendant at delivery, access to emergency obstetric care in the event of a complication, and a referral system to ensure that women experiencing complications can reach life-saving care in adequate time. (13)

In its latest report, the World Health Organization noted that the world's nations are not close to attaining this goal. (14) The global maternal mortality rate has declined only 1% each year between 1990 and 2005, far from the 5.5% needed to reach the target goal. (15) Conditions are worse in sub-Saharan Africa, where the annual decline has been about 0.1%. (16)

This Article assesses the barriers imposed by formal fees for health care services, more commonly known as user fees. The introduction of user fees in the 1980s arose following the publication of a significant body of literature detailing their efficacy. The World Bank was particularly instrumental in creating the original theoretical consensus for user fees as a viable health financing mechanism. (17) In 1985, the World Bank hailed user fees as "opportunities for greater cost recovery from users," and one of the four primary ways to improve health care financing in developing countries. (18) Since that time, many studies have more thoroughly examined user fees' progress in meeting their intended goals. (19) Some studies have emphasized the changes needed to make user fees more successful, including the implementation of better exemption policies. (20) Others have highlighted evidence demonstrating that user fees have not improved health service delivery in developing countries. (21) Selected studies have focused on the gender inequities inherent in health care systems, specifically pointing out the inequity of cost burdens for women. (22) Increasingly, studies frame maternal health as a human right. (23)

This Article draws on scholarship from the health policy and human rights fields to show that user fees dangerously impede access to urgently needed maternal health care. Such fees create significant roadblocks to the fulfillment of the MDGs in many regions of the world, dramatically altering the trajectory of maternal deaths by hampering access to health care, particularly in emergency care settings. User fees have failed to meet their stated purpose of generating funds for health programs, the rationale for their implementation. Instead, user fees prevent vulnerable individuals from seeking out and receiving necessary health care.

The global community must eliminate user fees for maternal health services to meet the goal of dramatically reducing maternal mortality by 2015. If it fails to do, the world's nations will not only fall short of attaining the global goal, they will also fail to protect the human rights of a large subset of their citizens.

This Article analyzes user fees' adverse impact on maternal mortality rates through the lens of human rights. It first provides an analysis of user fees, including how they are defined and how they interact with the other costs women confront when accessing key maternal health services. The Article then discusses the history of user fees, from the widespread implementation of user fees by developing countries under pressure from multilateral lenders and aid organizations to the more recent rethinking of user fees in light of their well-recognized harms. Despite the revision of user fee policies, they remain prevalent in developing countries due, in part, to conditional loans from organizations like the World Bank that advocate free-market principles in the provision of social services.

Next, the Article looks at user fees and maternal health. It documents how user fees have detrimentally impacted women across the globe and contributed to high rates of maternal mortality. In light of user fees' harmful impact on women, the Article then examines whether these fees have achieved any of the economic and systemic goals that accompanied their introduction. It shows that user fees have fallen short of their stated goals: exemptions meant to act as a safeguard for the poorest community members have failed to reach their intended recipients; user fees have failed to generate significant revenue for the health sector or increase efficiency; they have made no significant improvements in the quality of care or promoted equity in the provision of health care; and user fees have not decentralized health care provision to increase accountability and community participation.

The Article then applies human rights as a framework to evaluate user fees' impact on maternal health. The framework emphasizes the principle of non-discrimination: all citizens are entitled to human rights, including poor, geographically disadvantaged, and ethnic minority women of childbearing age. By focusing a lens on these women, one can gauge the global community's success in realizing human rights for all citizens. Notably, the millennium goal regarding maternal health assesses aggregate improvements in women's health status. A human rights framework, in contrast, delves deeper by providing each woman with her own assessment of her health status. (24) The Article shows that from a human rights perspective, user fees have failed to secure the rights to nondiscrimination, health and life. In order to provide disadvantaged women with the right to health, states must eliminate barriers to service and ensure affordable maternal health services.

Finally, the Article explores several alternatives to user fees, such as, for example, the taxation and insurance provisions employed by Ghana. (25) It evaluates these alternatives against the backdrop of the great debt burdens confronting many developing countries. The Article offers lessons for international lending institutions and wealthy states that will benefit the poor and ensure accountability. The Article concludes by offering a series of recommendations regarding eliminating user fees and instituting more gender sensitive health care financing schemes. These recommendations draw on human rights principles and offer a feasible path to attaining the millennium consensus goals regarding maternal health.

1. USER FEES: ANALYSIS

   Costs associated with maternal health fall into two broad categories: formal fees and informal costs.

   1. Formal Fees

      Formal fees, those most commonly discussed in the literature, tend to be explicit charges at the point of service for medical treatment provided. (26) The fees can be retained at the point of service or aggregated at the national level, and may be used to support capital or recurring costs. (27) Formal fees may include consultation fees, rental fees for a hospital bed, registration fees, and fees for medicine, blood or laboratory tests. (28) Insurance and other risk-sharing financing schemes tend to address these fees. (29)

   2. Informal Costs

      There often are a large number of related costs that households must bear in order to access services related to maternal health, such as transportation costs to reach the hospital. (30) In order to travel to receive care, many women must bring family members with them and pay the associated costs for their travel, food, and lodging. (31) Women also face the opportunity cost of lost work during the time they are away seeking medical care. (32) The sum of these costs can be substantial and presents significant barriers to accessing service. (33) This is especially true for women living in remote, rural areas with only intermittently accessible medical service. (34)

      In this Article, we use the term user fees to represent the state-imposed...