"Poverty is the big thing": exploring financial, transportation, and opportunity costs associated with fistula management and repair in Nigeria and Uganda.

BACKGROUND: Women living with obstetric fistula often live in poverty and in remote areas far from hospitals offering surgical repair. These women and their families face a range of costs while accessing fistula repair, some of which include: management of their condition, lost productivity and time, and transport to facilities. This study explores, through women's, communities', and providers' perspectives, the financial, transport, and opportunity cost barriers and enabling factors for seeking repair services. METHODS: A qualitative approach was applied in Kano and Ebonyi in Nigeria and Hoima and Masaka in Uganda. Between June and December 2015, the study team conducted in-depth interviews (IDIs) with women affected by fistula (n = 52) - including those awaiting repair, living with fistula, and after repair, and their spouses and other family members (n = 17), along with health service providers involved in fistula repair and counseling (n = 38). Focus group discussions (FGDs) with male and female community stakeholders (n = 8) and post-repair clients (n = 6) were also conducted. RESULTS: Women's experiences indicate the obstetric fistula results in a combined set of costs associated with delivery, repair, transportation, lost income, and companion expenses that are often limiting. Medical and non-medical ancillary costs such as food, medications, and water are not borne evenly among all fistula care centers or camps due to funding shortages. In Uganda, experienced transport costs indicate that women spend Ugandan Shilling (UGX) 10,000 to 90,000 (US$3.00-US$25.00) for two people for a single trip to a camp (client and her caregiver), while Nigerian women (Kano) spent Naira 250 to 2000 (US$0.80-US$6.41) for transportation. Factors that influence women's and families' ability to cover costs of fistula care access include education and vocational skills, community savings mechanisms, available resources in repair centers, client counseling, and subsidized care and transportation. CONCLUSIONS: The concentration of women in poverty and the perceived and actual out of pocket costs associated with fistula repair speak to an inability to prioritize accessing fistula treatment over household expenditures. Findings recommend innovative approaches to financial assistance, transport, information of the available repair centers, rehabilitation, and reintegration in overcoming cost barriers.

Improving Access to Delivery Care and Reducing the Equity Gap Through Voucher Program in Bangladesh: Evidence From Difference-in-Differences Analysis.

To test a statistically significant change in delivery by medically trained providers following introduction of a demand-side financing voucher, a population-based quasi-experimental study was undertaken, with 3,300 mothers in 2010 and 3,334 mothers at follow-up in 2012 in government-implemented voucher program and control areas. Results found that voucher program was significantly associated with increased public health facility use (difference-in-differences (DID) 13.9) and significantly increased delivery complication management care (DID 13.2) at facility although a null effect was found in facility-based delivery increase. A subset analysis of the five well-functioning facilities showed that facility deliveries increased DID 5.3 percentage points. Quintile-based analysis of all facilities showed that facility delivery increased more than threefold in lower quintile households comparing to twofold in control sites. The program needs better targeting to the beneficiaries, ensuring available gynecologist-anesthetist pair and midwives, effective monitoring, and timely fund reimbursements to facilities.

Distance, transportation cost, and mode of transport in the utilization of facility-based maternity services: evidence from rural Bangladesh.

Although the maternal mortality ratio in Bangladesh has decreased, significant underutilization of facilities continues to be a persistent challenge to policy makers. Women face long distances and significant transportation cost to deliver at health facilities. This study identifies the distance traveled to utilize facilities, associated transportation cost, and transport mode used for maternal healthcare services. A total of 3,300 mothers aged 18-49 years, who had given birth in the year before the survey, were interviewed from 22 sub-districts in 2010. Findings suggest that facility-based maternal healthcare service utilization was very poor. Only 53% of women received antenatal care, 20% used delivery care. and 10% used postnatal care from health centers. Median distance traveled for antenatal and postnatal check-ups was 2 kilometers but 4 kilometers for complication management care and delivery. Most women used non-motorized rickshaw or van to reach a health facility. On average, women spent Taka 100 (US$1.40) as transportation cost for antenatal care, Taka 432 (US$6.17) for delivery, and Taka 132 (US$1.89) for postnatal check-up. For each additional kilometer, the cost increased by Taka 9 (US$0.13) for antenatal, Taka 31 (US$0.44) for delivery, and Taka 8 (US$0.11) for postnatal care.