Financial implications of skilled attendance at delivery in Nepal

Summary Objective To measure costs and willingness‐to‐pay for delivery care services in 8 districts of Nepal. Method Household costs were used to estimate total resource requirements to finance: (1) the current pattern of service use; (2) all women to deliver in a health facility; (3) skilled attendance at home deliveries with timely referral of complicated cases to a facility offering comprehensive obstetric services. Results The average cost to a household of a home delivery ranged from 410 RS ($5.43) (with a friend or relative attending) to 879 RS ($11.63) (with a health worker). At a facility the average fee for a normal delivery was 678 RS ($8.97). When additional charges, opportunity and transport costs were added, the total amount paid exceeded 5300 RS ($70). For a caesarean section the total household cost was more than 11 400 RS ($150). Based on these figures, the cost of financing current practice is 45 RS ($0.60) per capita. A policy of universal institutional delivery would cost 238 RS ($3.15) per capita while a policy of skilled attendance at home with early referral of cases from remote areas would cost around 117 RS ($1.55) per capita. These are significant sums in the context of a health budget of about 400 RS ($5) per capita. Conclusions The financial cost of developing a skilled attendance strategy in Nepal is substantial. The mechanisms to direct funding to women in need must to be improved, pricing needs to be more transparent, and payment exemptions in public facilities must be better financed if we are to overcome both supply and demand‐side barriers to care seeking. Objectifs Mesurer les coûts et la volonté de payer pour les soins d'accouchement dans huit districts. Méthode Les dépenses familiales ont été utilisées pour estimer les ressources totales requises pour financer: (1) le profil en cours des services utilisés, (2) l'accouchement de toutes les femmes dans un service de santé et (3) l'accouchement à domicile avec une assistance qualifiée, incluant un transfert à temps des cas compliqués dans un cadre offrant des services obstétriques approfondis. Résultats Le coût moyen par foyer pour l'accouchement à domicile variait de 410 RS ($5,43) (avec assistance d'un amie ou d'un parent) à 879 RS ($11,63) (avec un professionnel de la santé). L'accouchement normal dans un service spécialisé revenait à 678 RS ($8,97). Quand on ajoute les frais supplémentaires, l'opportunité et le transport, le coût total pour le foyer revenait à pl