Exploring barriers and financial factors for maternal and newborn health service utilization: a comparision between areas served dy contracted and non-contracted rural health centres in the selected districts of Pakistan

Date of Award


Document Type


Degree Name

Master of Science in Health Policy & Management (MSc Health Policy & Mgmt)


Community Health Sciences


Exploring barriers and financial factors for Maternal and Newborn health (MNH) service utilization: A comparison between areas served by contracted and non-contracted Rural Health Centres in the selected districts of Pakistan. Background: Maternal and neonatal mortality particularly in perinatal period is a grave issue in resource poor settings. Evidence suggests that maternal and newborn mortality is strongly associated with MNH service utilization. Furthermore, there is growing evidence on association of MNH service utilization and poor access to healthcare services and financial barriers. Like other developing countries, there is now growing trend of contracting health facilities to NGOs in Pakistan to improve utilization of health care services. The effectiveness of contracting health facilities on improving MNH service supply is supported by studies from developing countries. However, influence of contracting on financial factors (including relative role of financial barriers compared to other barriers, willingness to pay for MNH services, coping mechanisms in case of inability to pay, and economic autonomy of women) for MNH service utilization is understudied. Aim of this study was to explore barriers, financial factors and underlying dynamics influencing MNH service utilization by mothers in remote rural areas, and improvements if any with contracting RHCs. Methodology: A qualitative exploratory study design was used and secondary data analysis of FGDs was carried out. Data coming from FGDs was part of a parent study assessing comparative effectiveness of contracted RHCs Vs. non-contracted RHCs in providing access to quality MNH services and reduction of financial barriers in Pakistan. FGDs were conducted purposively with pregnant/ recently delivered women and a separate set with their spouses due to their key role in household expenditure and decision making. These FGDs were conducted during April to July 2012, in catchment areas of contracted and non-contracted RHCs in district Thatta and Chitral. Analysis of data coming from FGDs was carried out with the help of qualitative data analysis software NVIVO 10.0. Using inductive approach; thematic analysis was carried out after summarizing data and coding. Findings: Sub-themes highlighting barriers to MNH service utilization portrayed supply side issues (issues related to service delivery), financial constraints, poor physical access and cultural and traditional practices as hindering factors to MNH service utilization. Although contracting RHCs reduced issues related to healthcare supply but it had no influence on physical access, financial constraints and coping. Cultural/traditional practices also remained same. Financial constraints became more salient in areas served by contracted RHCs whereas supply side issues were of most importance in areas served by non-contracted RHCs. Willingness to pay was highest for emergency healthcare services and least for preventive healthcare services in both contracted and non-contracted. Coping was similar in both areas and included mainly efforts to manage money at household level, institutional level, societal level and compromising healthcare in case of inability to manage funds. Women's economic autonomy and role in decision making was also similar in both areas served by contracted and non-contracted RHCs, highlighting husband's role as a decision maker in most of circumstances and women in a subjugated position. Furthermore, culture and norms, religion and belief, gender roles, women education, and earning were perceived factors influencing women's autonomy. Conclusion: This study highlights that MNH users face plentiful barriers in rural areas of Pakistan. These barriers include supply side constraints, financial constraints, difficult physical access and cultural/traditional constraints. Furthermore, supply side constraints are more in non-contracted and less in contracted RHCs. Financial constraints are perceived relatively more important in areas of contracted RHCs indicating that contracting alone is not enough and need accompanied measures such as financial safety nets for those who cannot afford. Furthermore, there is need of revisiting pricing of healthcare services taking MNH users on board and knowing their ability to pay. Women's economic and household autonomy is very poor and highlights need of programs focusing empowerment of women.

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