There is a growing consensus that maternal health outcomes can only be improved through policies and programmes that combine interventions to address the different causes of ill health and target multiple groups. Such policies and programmes are complex in nature as they involve coordination between different tiers in the health system and multiple actors including communities, health workers and managers.
User fee exemption for delivery and emergency obstetric care (EmOC) is one such policy that has been introduced by several African countries with the aim of improving access to care and thus improving maternal and neonatal outcomes. However, the current evidence base regarding the impact of this policy is not well developed, in part because of evaluation designs that are not able to capture all the necessary information for policy-makers to make informed decisions.
This programme aims to reduce this gap by developing research methodologies and tools that will lead to enhanced research on policy implementation, stronger evidence and improved dissemination.
- Programme Objective
1. To develop enhanced methods for the evaluation of complex interventions involving various levels of the health system and carried out on a large scale. Innovation will relate to the following areas:
- developing a policy implementation measurement tool that describes interventions in terms of their adherence to original objectives, their eventual scope and penetration;
- developing innovative methodologies for health policy analysis, focusing on what drives policy change and how policy is transferred, both from international to national level (and back), but also regionally;
- developing a Policy Effects Mapping tool (POEM) and a comparative case study design, based on realist evaluation that focuses on adequacy and plausibility of effect of intervention rather than on probability and provides policy relevant information;
- using critical events (near miss) as an entry point for the evaluation of health outcomes and quality of care;
Tools will be developed in year one, tested in year two and finalised for external use in year three.
2. To apply these enhanced research methods to evaluate the impact, cost-effectiveness and mechanisms of fee exemptions for delivery care, especially emergency delivery care, in Benin, Mali, Morocco and Burkina Faso.
The evaluation results will be generated by the start of year three. These will be synthesised regionally and disseminated within that year.
3. To pilot a new way of synthesising and disseminating results to policy-makers using a network beyond the four countries - a ‘community of practice’ which encourages cross-learning between policy-makers, international organisations and researchers and between countries in the region.
The CoP will be established from the start of the project, and will continue after the project’s end, if it is positively evaluated, both internally and externally.
- Download a short summary of the FEMHealth programme.
- Innovations in Methodology
FEMHealth will develop research and evaluation methodologies that allow assessment of policy interventions in complex situations. Our methods are innovative in a number of ways. First, FEMHealth will explore the process of policy success in terms of policy transfer and implementation by examining the interfaces between three levels of the healthcare system.
Second, we will conduct comparative realist case studies (Pawson & Tilley 1997), a promising but yet little applied approach to evaluation of interventions in complex situations, such as local health systems.
Third, we will use critical events (near miss) as an entry point for the evaluation of health outcomes and quality of care.
Lastly, we will pilot a new way of synthesising and disseminating results to policy-makers using a network beyond the four countries - a ‘community of practice’ which encourages cross-learning between policy-makers, international organisations and researchers and between countries in the region.
- Read the FEMHealth final reports and policy briefs.
- Background Publications
Some recent publications of relevance by the research group members
Health financing and exemption policies
McPake, B., Witter, S., Ensor, T., Fustukian, S., Newlands, D., Martineau, T. (2013) Removing financial barriers to access reproductive, maternal and newborn health services: the challenges and policy implications for human resources. Human Resources for Health, 11(1):46. http://www.human-resources-health.com/content/11/1/46/abstract
Witter, S., Jones, A., Ensor, T. (2013) How to (or not to)...measure performance against the Abuja target for public health expenditure. Health Policy and Planning doi: 10.1093/heapol/czt031
Chirwa, Y., Witter, S., Munjoma, M., Mashange, W., Ensor, T., McPake, B., Munyati, S. (2013) The human resource implications of improving financial risk protection for mothers and newborns in Zimbabwe. BMC Health Services Research 2013, 13:197 http://www.biomedcentral.com/1472-6963/13/197/abstract
Witter, S., Garshong, B, Ridde V. (2013) An exploratory study of the policy process and early implementation of free NHIS coverage for pregnant women in Ghana. International Journal for Equity in Health, 12:16. http://www.equityhealthj.com/content/12/1/16
Witter, S. and Ensor, T. (2012) Financing maternal health care services' in Hussein, McCaw-Binns, and Webber, eds, Maternal and perinatal health in developing countries, CABI.
Witter, S, Khalid, K, Abdel-Rahman, M, Hussein, R., Saed, M. (2012) 'Removal of user fees for caesareans and under-fives in northern Sudan: a review of policy implementation and effectiveness.' International Journal of Health Planning and Management.
Witter, S. and Somanathan, A. (2011) Demand-side financing for sexual and reproductive health services in low and middle-income countries: A review of the evidence. Policy Research Working Paper 6213.
Meessen, Bruno Gilson, Lucy and Tibouti, Abdelmajid (2011) 'User fee removal in the health sector in low-income countries: lessons from recent national initiatives' Health Policy & Planning Guest Editors: Volume 26 suppl 2 November
Witter, S. and Ensor, T. (2010) Financing maternal health care services’ in Hussein, McCaw-Binns, and Webber, eds, Maternal and perinatal mortality in developing countries, CABI.
Fabienne, R., Witter, S., De Brouwere, V. (2010) Reducing financial barriers to obstetric care in low-income countries: learning lessons on implementation and impact from recent experiences. American Journal of Public Health.
Witter S. (2010) Mapping user fees for health care in high-mortality countries – evidence from a recent survey. HLSP Institute Paper, London
De Brouwere, V., Richard, F. and Witter, S. (2010) Access to maternal and perinatal health services: lessons from successful and less successful examples of improving access to safe delivery and care of the newborn. Tropical Medicine and International Health 15(8), 901-9.
Witter, S., Dieng, T., Mbengue, D., Moreira, I., and De Brouwere, V. (2010) The free delivery and caesarean policy in Senegal – how effective and cost-effective has it been? Health Policy and Planning, 25(5), pp 384-392.
Witter, S., Service- and population-based exemptions: are these the way forward for equity and efficiency in health financing in low income countries? Advances in Health Economics and Health Services Research (2009), vol. 21, p. 249-286. Innovations in health systems finance in developing and transitional economies. Eds. Dov Chernichovsky and Kara Hanson.
Witter, S., Drame, F., Cross, S. (2009) Community perspectives on a maternal fee exemption policy in Senegal. African Journal of Midwifery and Women’s Health, vol. 3, no. 1, p.5 -10.
Witter, S., Adjei, S., Armar-Klemesu, M. & Graham, W. (2009) Providing free maternal health care: ten lessons from an evaluation of the national delivery exemption policy in Ghana. Global Health Action, vol. 2.
Witter, S. & Diadhiou, M. (2008) Key informant views of a free delivery and caesarean policy in Senegal. African Journal of Reproductive Health, vol. 12, no. 5.
Witter, S, Richard, F, De Brouwere, V. (2008) Learning lessons and moving forward: how to reduce financial barriers to obstetric care in low-income contexts. In ‘Reducing financial barriers to access to obstetric care’, edited by Richard, F., Witter, S. and De Brouwere, V. Studies in Health Services Organisation and Policy series. Antwerp: ITG Press.
Witter, S., Armar-Klemesu, M. and Dieng, T. (2008) National fee exemption schemes for deliveries: comparing the recent experiences of Ghana and Senegal. Chapter in ‘Reducing the financial barriers to access to obstetric care’, edited by Richard, F., Witter, S. and De Brouwere, V. Studies in Health Services Organisation and Policy series. Antwerp: ITG Press.
Witter, S, Arhinful, D., Kusi, A., Zakariah-Akoto, S. (2007) The experience of Ghana in implementing a user fee exemption policy to provide free delivery care. Reproductive Health Matters 15(30), p. 1-11.
Witter, S. and Adjei, S. (2007) Start-stop funding, its causes and consequences: a case study of the delivery exemptions policy in Ghana. International Journal of Health Planning and Management, 22 (2).
Maternal health in general
Filippi V, Ronsmans C, Campbell OM, Graham WJ, Mills A, Borghi J, Koblinsky M, Osrin D. 2006. Maternal health in poor countries: the broader context and a call for action. Lancet 368 (9546): 1535–41.
Ronsmans C, Graham WJ, on behalf of The Lancet Maternal Survival Series steering group. 2006. Maternal mortality: who, when, where, and why. Lancet. 30 September 368 (9542):1189-1200
Near-miss and quality of care
Hutchinson C, Lange I, Kanhonou L, Filippi V, Borchert M. Exploring the sustainability of near-miss obstetric case reviews: a qualitative study in Benin. Midwifery 2010; 26(5):537-43.
Filippi V, Richard F, Lange I, Ouattara F. 2009. Identifying barriers from home to the appropriate hospital through near-miss audits in developing countries
Best Practice and Research Clinical Obstetrics and Gynaecology, 23: 389-400
Ronsmans C. 2009. Severe acute maternal morbidity in low income countries
Best Practice & Research Clinical Obstetrics & Gynaecology 23:305-316
Ronsmans, C.; Scott, S.; Adisasmita, A.; Deviany, P.; Nandiaty, F. Estimation of population-based incidence of pregnancy-related illness and mortality (PRIAM) in two districts in West Java, Indonesia BJOG-an International Journal of Obstetrics and Gynaecology, 2009; 116(1):82-90
Asri Adisasmita, Poppy E Deviany, Fitri Nandiaty, Cynthia Stanton, and Carine Ronsmans. Obstetric near miss and deaths in public and private hospitals in Indonesia. BMC Pregnancy Childbirth. 8: 10. Published online 2008 March 12. doi:
Béhague DP, Kanhonou LG, Filippi V, Lègonou S, Ronsmans CPierre Bourdieu and transformative agency: a study of how patients in Benin negotiate blame and accountability in the context of severe obstetric events. 2008 Sociol Health Illn 30:489-510.
Filippi V, Ronsmans C, Gohou V, Goufodji S, Lardi M, Sahel A, Saizonou J, De Brouwere V. Maternity wards or emergency obstetric rooms? Incidence of near-miss events in African hospitals. Acta Obstetrica et Gynaecologica Scandinavica 2005 84:11-16.
Stanton C, Dubourg D, De Brouwere V, Pujades M, Ronsmans C. Reliability of Developing Country Caesarean Section Data. Bulletin WHO 2005; 83:449-455.
Filippi V, Brugha R, Browne E, Gohou V, Bacci A, De Brouwere V, Sahel A, Goufodji S, Alihonou E, Ronsmans C. (How to do (or not to do)… Obstetric audit in resource poor settings: lessons from a multi-country project auditing ‘near-miss’ obstetrical emergencies. Health Policy and Planning. 2004 19(1):57-66
Pittrof R, Campbell O, Filippi V What is quality in maternity care? An international perspective. Acta Obstetricia et Gynecologica Scandinavica 2002; 81(4):277-83
Maternal near-miss: a valuable concept for improving safe motherhood in low income countries. May 2010. Towards 4+5 Briefing paper number 7
Impact of costs/near-miss
The consequences of severe obstetric complications in Burkina Faso and Benin. April 2009. Towards 4+5 Briefing paper number 3
Ganaba R Ganaba R, Marshall T, Sombié I, Baggaley RF, Ouédraogo TW, Filippi V. Women's sexual health and contraceptive needs after a severe obstetric complication ("near-miss"): a cohort study in Burkina Faso. Reprod Health. 2010 Aug 27;7:22.
Fottrell Filippi V, Goufodji, S, Sismanidis C, Kanhonou L, Fottrell E, Ronsmans C, Alihonou E, Patel V. Effects of severe obstetric complications on women’s health and infant mortality in Benin. Tropical Medicine and International Health 2010 15(6): 733-742
Storeng K, Murray S, Akoum M, Ouattara F, Filippi V. Beyond body counts: a qualitative study of lives and loss in Burkina Faso after “near miss” obstetric complications. Social Sciences and Medicine. 2010 71 (10):1749-56
E, Kanhonou L, Goufodji S, Behague DP, Marshall T, Patel V and Filippi V. Risk of psychological distress following severe obstetric complications in Benin: the role of economics, physical health and spousal abuse. The British Journal of Psychiatry. (2010) 196, 18–25
Borghi J, Storeng K, Filippi V. 2009. Overview of costs of obstetric care and the economic and social consequences for households. Chap 1 in: Richard F, Witter S, De Brouwere V (eds) Reducing financial barriers to obstetric care in low income countries.
Storeng KT, Baggaley RF, Ganaba R, Ouattara F, Akoum MS, Filippi V. Paying the price: the cost and consequences of emergency obstetric care in Burkina Faso. Soc Sci Med. 2008 Feb;66(3):545-57. Epub 2007 Dec 3.
Filippi V, Ganaba R, Baggaley RF, Marshall T, Storeng KT, Sombié I, Ouattara F, Ouedraogo T, Akoum M, Meda N.. Health of women after severe obstetric complications in Burkina Faso: a longitudinal study. Lancet. 2007 Oct 13;370(9595):1294-5.
Human resources and obstetric care
Cometto, G. And Witter, S. (2013) Tackling health workforce challenges to universal health coverage: setting targets and measuring progress. WHO Bulletin special edition on HRH and UHC, vol. 3;91:881–885. http://www.who.int/bulletin/volumes/91/11/13-118810.pdf
Witter, S., Cometto, G., Zaman, R., Sheikh, M., Wibulpolprasert, S. (2013) Implementing the Agenda for Global Action on human resources for health: analysis from an international tracking survey. Journal of Hospital Administration, vol. 2, no. 1, p. 77-87. http://www.sciedu.ca/journal/index.php/jha/article/view/1843/1128
De Brouwere, V., Dieng, T., Diadhiou, M., Witter, S., Denerville, E. (2009) Task shifting in emergency obstetric surgery: results from a national evaluation in Senegal. Reproductive Health Matters, vol. 17 (33), pp. 32–44.
McCoy, D., Bennett, S., Witter, S. et al. (2008) Health worker salaries and incomes in sub-Saharan Africa. The Lancet, vol 371, p. 677-83.
Witter, S., Kusi, A. and Aikins, M. (2007) Effects of a delivery exemption scheme on workloads and incomes of health workers in Ghana. Human Resources for Health journal, vol 5; 2.
Getting research into policy & practice
Walley, J., Khan, A., Shah, S., Witter, S., & Wei, X. (2007) How to get research into practice – first get practice into research. WHO Bulletin, June 2007.
Health systems research
Witter, S., Toonen, J., Meessen, B., Kagubare, J., Fritsche, G. and Vaughan, K. (2013) Performance-based financing as a health system reform– mapping the key dimensions for monitoring and evaluation. BMC Health Services Research, 13:36. http://www.biomedcentral.com/1472-6963/13/367