In 2018, the What Women Want campaign listened to the healthcare demands of 1.2 million women and girls in 114 countries to amplify their voices and better understand what they want for their own reproductive and maternal health. Free and affordable care and full functioning, geographically reachable health facilities were among the top demands. All women should have the right to choose to receive quality care from a capable provider and in a clean facility. Nevertheless, affordable, and geographically accessible quality of care is often unattainable in many parts of the world and thus many women do not get this choice. These demands highlight that financial and geographical accessibility alongside quality need to be prioritized in maternal health.
These issues are an integral part of the Strategies toward Ending Preventable Maternal Mortality (EPMM) report, which was published by the World Health Organization (WHO) in 2015 to serve as a global framework for maternal health during the Sustainable Development Goals (SDGs). Grounded in human rights, the report emphasizes effective healthcare financing to reduce inequities and end preventable maternal mortality. At the end of 2018, the Improving Maternal Health Measurement (IMHM) Project gathered subject matter experts from around the world to review the EPMM indicators and develop recommendations to strengthen them.
The EPMM Strategies report takes a comprehensive view of maternal health and survival, and the EPMM indicators reflect measures for monitoring this broad spectrum of risk factors. Nevertheless, measurement experts found a variety of issues with the metrics that can make their implementation challenging. These include issues related to how the indicators were defined, how they are calculated, and the data sources used to compile them. While the indicators examined fell into two categories — Maternal Health Policy and Maternal Health Financing — this blog will focus on the Health Financing indicators, which aim to improve equity, quality of care, and coverage by strengthening maternal health financing mechanisms.
Dr. Aminu Magashi Garba (MBBS, MScPH (Lond), DLSHTM) is the founder, coordinator, and Chief Executive Officer of the Africa Health Budget Network (AHBN), a budget advocacy organization whose goal is to improve health service delivery in Africa. The MHTF has asked Dr. Garba to share his perspective as an expert in the field of health financing and a valued participant in the expert consultations that developed the recommendations for strengthening EPMM indicators.
What are health financing indicators?
Health financing indicators help us understand the financial resources available for a specific intervention. They are used to analyze financing mechanisms of individual countries, governments, and programs and help us evaluate spending in terms of efficiency and equity. For example, reviewing whether an investment in a certain area (e.g., family planning) has led to increased utilization (e.g., more people seeking and using family planning services).
Health financing indicators selected for tracking the EPMM Key Themes (EPMM Key Themes can be found in Table 2 of Jolivet et al. 2018)
This table summarizes the importance of each health financing indicator, according to Dr. Aminu Garba.
| Health Financing Indicator | Importance |
| Out-of-pocket expenditure as a percentage of total expenditure on health | Serves as evidence to show that high out-of-pocket costs are a significant burden for women, which could prompt the government to act. |
| Are the following (maternal health-related) services provided free of charge at point of use in the public sector for women of reproductive age? | Allows for the monitoring and evaluation of universal health coverage (UHC) progress. |
| Costed implementation plan for maternal, newborn, and child health | Allows the government and its partners to plan and allocate money for maternal health projects. |
| Annual reviews are conducted of health spending from all financial sources, including RMNCH spending, as part of broader health sector reviews | Helps the government monitor progress, review performance, and plan accordingly.
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| Percentage of total health expenditure spent on reproductive, maternal, newborn, and child health | Allows for the direct comparison of maternal health spending and other areas, for example, immunization. Helps track progress, improve investment, and promote transparency in the budget. |
A common problem for many of the financing indicators was the lack of disaggregation (break down) in health financing data. In the context of maternal health, why is it important to disaggregate health financing data by the funding source, spending, and the specific health condition?
Some countries in Africa allocate a lump sum of money for the broad category of Reproductive, Maternal, Newborn, and Child Health (RMNCH). This approach creates issues for implementation because it becomes difficult to determine how much money to allocate to a particular issue or area. Separating by funding source is important because it helps us identify the partners that are delivering versus those that are not.
What is the current state of monitoring of the selected maternal health financing indicators globally and in Africa?
The current state in Africa is weak as there is a lack of country ownership. While there are monitoring mechanisms in place, they are mostly donor-driven. Within the African Union, The Global Fund, The Global Financing Facility, and African Leaders Malaria Alliance help countries track these indicators. Globally, The World Bank, WHO, OECD, and other similar organizations do this work.
From your perspective in the African context, which recommendations will have the greatest impact on maternal health and why?
Many countries in Africa and around the world have decentralized health systems. Thus, focusing and developing a costed plan for solely the federal government misses a lot of people and opportunities. In the African context, countries should look to expand the definition of a national implementation plan to include subnational plans (recommendation #4 – Indicator 8). For instance, in Nigeria, many healthcare workers and people rely on the 36 state governments to provide support, salaries, drugs, and human resources for healthcare facilities. Having a specific costed plan for each subnational region in addition to the compiled national plan will help evaluate the distribution of resources in terms of financial and geographical equity, which will promote equitable maternal health outcomes in the long term.
Moreover, out-of-pocket (OOP) expenditure is often reported as a lump sum. Knowing the specific breakdown on maternal health spending (antenatal care, postnatal care, delivery, etc.) can help us understand where women spend most OOP. Addressing OOP expenditure on maternal health specifically (recommendation #1 – Indicator 6), will allow countries to understand the gravity of the challenges that women are facing to access care. Therefore, it will allow policymakers to propose meaningful and specific recommendations to the government about allocating and mobilizing resources to improve maternal health equity.
What are the next steps for health financing indicators?
All in all, health financing indicators can improve maternal health by quantifying how financial investment in maternal health improves maternal health outcomes. By addressing key issues and implementation challenges, the recommendations made to strengthen the EPMM maternal health financing indicators will facilitate tracking and analyzing the progress on addressing the important underlying health system issues measured through these core indicators (effective resource allocation, budget accountability, equity, and universal coverage, etc.). Monitoring maternal health financing indicators can also help keep governments accountable on their commitment to improving maternal health and equity. Out-of-pocket costs related to maternal health are a huge financial burden for women in countries around the world, and especially in developing settings. Close monitoring of data on out-of-pocket expenditure can drive policy change to help women face these challenges. We have all heard the catchphrase, “Follow the money!” These recommendations to further strengthen key maternal health financing indicators should make it easier for governments, citizens, measurement experts, and advocates to do just that.