TY - JOUR
T1 - "There is no free here, you have to pay"
T2 - actual and perceived costs as barriers to intermittent preventive treatment of malaria in pregnancy in Mali
AU - Klein, Meredith C.
AU - Harvey, Steven A.
AU - Diarra, Hawa
AU - Hurley, Emily A.
AU - Rao, Namratha
AU - Diop, Samba
AU - Doumbia, Seydou
N1 - Funding Information:
This work was supported by the Fogarty International Center under Grant Number D43TW008652. The views expressed in this manuscript are solely those of the authors and do not necessarily represent the official views of the Fogarty International Center or the National Institutes of Health. The authors are grateful to the research team; the University of Sciences, Techniques, and Technologies, Faculty of Medicine, Dentistry, and Pharmacy in Bamako; the NIH support staff in Bamako; and most of all to the study participants.
Publisher Copyright:
© 2016 Klein et al.
PY - 2016/3/12
Y1 - 2016/3/12
N2 - Background: "There is no free here," the words of a Malian husband, illustrate how perceptions of cost can deter uptake of intermittent preventive treatment of malaria in pregnancy (IPTp). The Malian Ministry of Health (MOH) recommends a minimum of three doses of IPTp at monthly intervals. However, despite a national policy that IPTp be provided free of charge, only 35 % of pregnant women receive at least one dose and less than 20 % receive two or more doses. Methods: This study explored perceptions and experiences of IPTp cost in Mali and their impact on uptake, using qualitative interviews and focus groups with pregnant women, husbands and mothers-in-law. Study team members also interviewed and observed health workers at four health centres, two in Sikasso Region and two in Koulikoro. Results: Despite national-level policies, actual IPTp costs varied widely at study sites - between facilities, and visits. Pregnant women may pay for IPTp, receive it free, or both at different times. Health centres often charge a lump sum for antenatal care (ANC) visits that includes both free and fee-based drugs and services. This makes it difficult for women and families to distinguish between free services and those requiring payment. As a result, some forego free care that, because it is bundled with other fee-based services and medications, appears not to be free. Varying costs also complicate household budgeting for health care, particularly as women often rely on their husbands for money. Finally, while health facilities operating under the cost-recovery model strive to provide free IPTp, their own financial constraints often make this impossible. Conclusions: Both actual and perceived costs are currently barriers to IPTp uptake. Given the confusion around cost of services in the two study regions, more detailed national-level studies of both perceived and actual costs could help inform policy and programme decisions promoting IPTp. These studies should evaluate both quantitatively and qualitatively the cost information provided to and understood by pregnant women and their families. Meanwhile, unbundling free and fee-based services, making clear that IPTp is free, and ensuring that it is provided at no cost could help increase uptake. Free community-based distribution might be another route to increased uptake and adherence.
AB - Background: "There is no free here," the words of a Malian husband, illustrate how perceptions of cost can deter uptake of intermittent preventive treatment of malaria in pregnancy (IPTp). The Malian Ministry of Health (MOH) recommends a minimum of three doses of IPTp at monthly intervals. However, despite a national policy that IPTp be provided free of charge, only 35 % of pregnant women receive at least one dose and less than 20 % receive two or more doses. Methods: This study explored perceptions and experiences of IPTp cost in Mali and their impact on uptake, using qualitative interviews and focus groups with pregnant women, husbands and mothers-in-law. Study team members also interviewed and observed health workers at four health centres, two in Sikasso Region and two in Koulikoro. Results: Despite national-level policies, actual IPTp costs varied widely at study sites - between facilities, and visits. Pregnant women may pay for IPTp, receive it free, or both at different times. Health centres often charge a lump sum for antenatal care (ANC) visits that includes both free and fee-based drugs and services. This makes it difficult for women and families to distinguish between free services and those requiring payment. As a result, some forego free care that, because it is bundled with other fee-based services and medications, appears not to be free. Varying costs also complicate household budgeting for health care, particularly as women often rely on their husbands for money. Finally, while health facilities operating under the cost-recovery model strive to provide free IPTp, their own financial constraints often make this impossible. Conclusions: Both actual and perceived costs are currently barriers to IPTp uptake. Given the confusion around cost of services in the two study regions, more detailed national-level studies of both perceived and actual costs could help inform policy and programme decisions promoting IPTp. These studies should evaluate both quantitatively and qualitatively the cost information provided to and understood by pregnant women and their families. Meanwhile, unbundling free and fee-based services, making clear that IPTp is free, and ensuring that it is provided at no cost could help increase uptake. Free community-based distribution might be another route to increased uptake and adherence.
KW - Cost
KW - Intermittent preventive treatment of malaria in pregnancy
KW - Malaria
KW - Malaria in pregnancy
KW - Mali
KW - Qualitative research
KW - West Africa
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UR - http://www.scopus.com/inward/citedby.url?scp=84960847472&partnerID=8YFLogxK
U2 - 10.1186/s12936-016-1210-0
DO - 10.1186/s12936-016-1210-0
M3 - Article
C2 - 26968167
AN - SCOPUS:84960847472
SN - 1475-2875
VL - 15
JO - Malaria journal
JF - Malaria journal
IS - 1
M1 - 158
ER -