References

AbouZahr C (1999). Disability Adjusted Life Years and Reproductive Health: A Critical Analysis. Reproductive Health Matters 7(14),118-129.

Anand K, Pandav C, Kapoor S et al. (1995). Cost of health services provided at a primary health centre. The National Medical Journal of India 8(4),156-161.

Ande B, Chiwuzie J, Akpala W et al. (1997). Improving obstetric care at the district hospital Ekpoma, Nigeria. International Journal of Gynecology and Obstetrics 59 (Suppl. 2), S47-S53.

Argentine Episiotomy Trial Collaborative Group (1993). Routine vs selective episiotomy: a randomised controlled trial. The Lancet 42,1517-18.

Barnum H & Kutzin J (1993). Patterns of hospital resource use. Chapter 2 in Public Hospitals in Developing Countries. John Hopkins University Press, Baltimore.

Berman P (1989). Cost efficiency in primary health care: studies of health facilities in Indonesia Health Policy and Planning 4(4),316-322.

Berman P, Quinley J, Yusuf B et al. (1991). Matrenal tetanus immunization in Aceh Province, Sumatra: the Cost-effectiveness of alternative strategies. Social Science and Medicine 33(2),185-192.

Bibi-M, Megdiche H, Ghanem H et al. (1994). L’antibioprophylaxie dans les Cesariennes a Priori sans ‘haute infectieux’ [Antibiotic infection in a prior caesarean sections without a high risk]. Journal de la Gynecologie et Obstetrie et de la Biologie Reproductive 23,451-455.

Borghi J, Bastus S, Belizan M et al. (2000). Costs of Publicly Provided Maternity Services in Rosario, Argentina. Submitted to the Pan-American Journal of Public Health.

Borghi J, Fox-Rushby J, Bergel E, Carroli G, Abalos E & Hutton G (2000b). Predicting Cost-effectiveness from a Cochrane Review of Effectiveness. Report submitted to the Global Forum for Health Research.

Carroli G et al. (1999). Episiotomy for Vaginal Birth. In Keise MJNC, Renfrew MJ, Neilson JP, Crowther C editors Pregnancy and Childbirth Database. Cochrane Database.

Chiwuzie J, Okojie O, Okolocha C et al. (1997). Emergency Loan funds to improve access to obstetric care in Ekpoma, Nigeria. International Journal of Gynecology and Obstetrics 59(Suppl. 2), S231-6.

Cowley P (1995). The Cost of Essential Obstetric Care. In Issues in Essential Obstetric care. Report of a technical Meeting of the Inter-Agency Group for Safe Motherhood. May 31-June 2, 1995. New York: Family Care International.

Djan JO, Kyei-Faried S, Twum S et al. (1997). Upgrading obstetric care at the health center level, Juaben, Ghana. International Journal of Gynecology and Obstetrics 59(Suppl. 2), S83-S90.

Dmytraczenko T, Aitken I, Carrasco S et al. (1998). Evaluacion del Seguro Nacional de Maternidad y Ninez en Bolivia. Informe Tecnico 22. Bethesda, MD: Partnerships for Health Reform Project, Abt Assoicates Inc.

Family Health International. (1996). Manuscript on the methodology and cost analysis for APROFE, the Ecuadorean IPPF affiliate. North Carolina: Family Health International.

Fofana P, Samai O, Kebbie A et al. (1997). Promoting the use of obstetric services through community loan funds, Bo, Sierra Leone. International Journal of Gynecology and Obstetrics 59(Suppl. 2), S225-30.

Fox-Rushby J & Foord F (1996). Costs, Effects and Cost-Effectiveness Analysis of a Mobile Maternal Health Care Service in West Kiang, The Gambia. Health Policy 35(2),123-143.

Galvez A, Galvez M, Sanabria G et al. (2000). Economic Evaluation Alongside an Antenatal Trial in Developing Countries: Report on Cuba. University of East Anglia Discussion Document.

Gold MR, Siegel JE, Russell LB & Weinstein MC (1996). Cost-effectiveness in health and medicine. Oxford University Press.

Grossman F, Filippi V, De Koninck M et al. (2000). Témoignages de Femmes: l’Expérience de la Maternité chez les Femmes Béninoises. Submitted to Reproductive Health Matters.

Hanson K (1999). Measuring Up: Gender, Burden of Disease, and Priority Setting Techniques in the Health Sector. Prepared under the Global Health Equity Initiative project on ‘Gender and Health Equity’ based at the Harvard Center for Population and Development Studies.

Hotchkiss D (1998). The tradeoff between price and quality of services in the Philippines. Social Science and Medicine 46(2),227-242.

Howard (1990)

Hsiao W (2000). A Preliminary Assessment of Sri Lanka’s Health Sector and Steps Forward. In conjunction with the Institute of Policy Studies Health Policy Programme, Sri Lanka. Cambridge, Massachusetts, USA.

http//:www.50years.org/update/userfees.html.

http//:www.phpr.com/publicat/hrps/finan.html

Hutton G (1996). A Review of Economic Evaluations of Interventions in Antenatal care in developing countries. Submitted to the Overseas Development Association.

Janowitz B & Bratt J (1992). Costs of family planning services: a critique of the literature. International Family Planning Perspectives 18.

Jinabhai C, Wamukuo J, Bagwandeen C et al. (2000). Costs of Antenatal and Delivery Care for Providers and Women in Umlazy Township, Durban, South Africa. University of East Anglia Discussion Document.

Johnson B, Benson J, Bradley J et al. (1993). Costs and resource utilization for the treatment of incomplete abortion in Kenya and Mexico. Social Science and Medicine 36(11),1443-1453.

Kawnine N, Guinness L, Amin M et al. (1998). Consumer costs of caesarean section in public, private and NGO health care facilities in Bangladesh. Research paper No. 7. Health Economics Unit, Ministry of Health and Family Welfare, Government of the People’s Republic of Bangladesh.

Knowles J (1998). Case Study: Benefit Incidence of Safe Motherhood services in Vietnam. Presented at the World Bank Institute Course: Adapting to Change.

Konje J, Obisesan K & Ladipo O (1992). Health and economic consequences of septic induced abortion. International Journal of Gynecology and Obstetrics 37,193-197.

Krasovec K & Shaw R (2000). Reproductive health and health sector reform: Linking outcomes to action. WBI Working Papers. World Bank Institute.

Kumaranayake L (2000). The real and the nominal. Making inflationary adjustments to cost and other economic data. Health Policy and Planning 15(2),230-234.

Leigh B, Kandeh H, Kanu M et al. (1997). Improving emergency obstetric care at a district hospital, Makeni, Sierra Leone. International Journal of Gynecology and Obstetrics 59(Suppl. 2), S55-S65.

Levin A, Amin A, Rahman A et al. (1999). Cost-effectiveness of family planning and maternal health service delivery strategies in rural Bangladesh. International Journal of Health Planning and Management 14,219-233.

Levin A, McEuen M, Dymatraczenko T et al. (2000). Costs of maternal health care services in three anglophone African countries. Special Initiatives Report 22. Bethesda MD: Partnerships for Health Reform Project, Abt Associates Inc.

Litvack J & Bodart C (1993). User fees plus quality equals improved access to health care: results of a field experiment in Cameroon. Social Science and Medicine 37(3),369-383.

Magotti R, Munjinja P, Lema R et al. (1995). Cost-effectiveness of managing abortions: Manual Vacuum Aspiration (MVA) compared to evacuation by curettage in Tanzania. East African Medical Journal 72(4),248-251.

Maine D (1999). The safe Motherhood Initiative: Why has it stalled? American Journal of Public Health 89(4),480-482.

Merrick T (1999). SWAPs and Reform: A Note on Bangladesh’s Experience. Revised Draft.

Michaud C & Murray C (1994). External assistance to the health sector in developing countries: a detailed analysis 1972-1990. Bulletin of the World Health Organisation 72(4),639-651.

Mintz P & Savedoff W (2000). PROSALUD and the insurance program for mothers and children (SNMN). The Challenge of health reform: reaching the poor. Europe and the Americas Forum on Health Sector Reform, San Jose, Costa Rica. May 24-26 2000. World Bank.

Mirembe F, Ssengooba F & Lubanga R (1998). Cairo in Action: Uganda Profile Report. Makerere University, Kampala and Population Reference Bureau Inc. Washington D.C.

Mitchell M, Littlefield J & Gutter S (1997). Reproductive Health: From Policy to Practice. Draft manuscript Boston: Management Sciences for Health.

Mitchell M, Thomason J, Domaldson D et al. (1991). The cost of rural health services in Papua New Guinea. Papua New Guinea Medical Journal 34,276-284

Mumford E, Dayaratna V, Winfrey W et al. (1998). Reproductive Health Cost: Literature Review. Working Paper Series No. 3. Futures Group International, Washington Dc, July.

Murray C & Lopez A (eds) (1998). Health Dimensions of Sex and Reproduction. World Health Organisation, Harvard School of Public Health, World Bank.

Murray C & Lopez A. (2000). Progress and directions in refining the global burden of disease approach: a response to Williams. Health Economics 9,69-82.

Nieves I & La Forgia G (2000). Large-scale government contracting of NGOs to extend basic health service to poor populations in Guatemala. The Challenge of health reform: reaching the poor. Europe and the Americas Forum on Health Sector Reform, San Jose, Costa Rica. May 24-26 2000. World Bank.

Olukoya A, Ogunyemi M, Akitoye C et al. (1997). Upgrading obstetric care at a secondary referral hospital, Ogun State, Nigeria. International Journal of Gynecology and Obstetrics 59(Suppl. 2), S67-S74.

Ottong J, Asuquo E, Olaniran N et al. (1997). Community mobilization for blood donation, Cross River State, Nigeria. International Journal of Gynecology and Obstetrics 59(Suppl. 2),S67-S74.

Oyesola A, Shehu D, Ikeh A et al. (1997). Improving emergency obstetric care at a state referral hospital, Kebbi State, Nigeria. International Journal of Gynecology and Obstetrics 59(Suppl. 2), S75-S81.

Post M (1997). Preventing Maternal mortality through Emergency Obstetric Care SAS Issues Paper

Potts M, Walsh J, McAninch J et al. (1999). Paying for reproductive health care: what is needed, and what is available? International Family Planning Perspectives 25 (Suppl.), S10-S16.

Rannan-Eliya R, Berman P, Eltigani E et al. (2000). Expenditures for Reproductive Health and Family Planning Services in Egypt and Sri Lanka. Revised Draft. Unpublished.

Rannan-Eliya R, Nada K, Kamal A et al. (1997). Egypt National Health Accounts 1994/5. Department of Planning, Ministry of Health and Population. Arab Republic of Egypt; Data for Decision-Making Project, Harvard School of Public Health, Harvard University.

Reggiori A, Ravera M, Cocozza E et al. (1996). Randomized Study of Antibiotic Prophylaxis for General and Gynecological Surgery for a Single Rural Centre in Africa. British Journal of Surgery.

Rosenthal G & Percy A (1991). Maternity services in Cochabamba, Bolivia: Costs, Cost-recovery and changing markets. Arlington VA: MotherCare, John Snow Inc.

Sabitu K, Alti-Mu’azu M, Musa A et al. (1997). The effect of improving maternity services in a secondary facility, Zaria, Nigeria. International Journal of Gynecology and Obstetrics 59(Suppl. 2), S99-S106.

Samai O & Sengeh P (1997). Facilitating emergency obstetric care through transportation and communication, Bo, Sierra Leone. International Journal of Gynecology and Obstetrics 59(Suppl. 2), S157-S164.

Samarasinghe D (1999). Women’s Health and Quality of Life. World Bank. Unpublished.

Schneider H & Gilson L (1999). The impact of free maternal health care in South Africa. Reproductive Health Matters 93-101.

Senah K, Richardson D, Kwofie G et al. (1997). From abandoned warehouse to life-saving facility. International Journal of Gynecology and Obstetrics 59(Suppl. 2), S91-S97.

Sengeh P, Samai O, Sidique S et al. (1997). Improving blood availability in a district hospital, Bo, Sierra Leone. International Journal of Gynecology and Obstetrics 59 (Suppl. 2), S127-S134.

Shehu D, Ikeh A & Kuna M (1997). Mobilizing transport for obstetric emergencies in northwestern Nigeria. International Journal of Gynecology and Obstetrics 59 (Suppl. 2), S173-S180.

Stanton B & Clemens J (1989). User fees for health care in developing countries: a case study of Bangladesh. Social science and medicine 29(10),1199-1205.

Suarez H & Brambila C (1994). Cost Analysis of Family Planning Services in Private Family Planning Programmes, FEMAP, Mexico. New York: INOPAL II, The Population Council.

Thinkamrop J, Thinkamrop B, Kuchaisit C et al. (2000). A study of the costs of antenatal care alongside the WHO trial in Thailand. University of East Anglia Discussion Document.

Thuray H, Samai O, Fofana P et al. (1997). Establishing a cost recovery system for drugs, Bo, Sierra Leone. International Journal of Gynecology and Obstetrics 59 (Suppl. 2), S141-S147.

Tinker A & Koblinsky M (1993). Making Motherhood Safe. World Bank Discussion Papers. The World Bank. Washington DC.

Weissman E, Sentumbew-Mugisa O, Mbonye A et al. (1999b). Uganda safe Motherhood Programme Costing Study. Ministry of Health Uganda, World Health Organisation.

Weissman E, Sentumbwe-Mugisa O, Mbonye A et al. (1999a). Costing Safe Motherhood in Uganda. Reproductive Health Matters. Blackwell Science.

Wilson J, Collison A, Richardson D et al. (1997). The maternity waiting home concept: the Nsawam, Ghana experience. International Journal of Gynecology and Obstetrics 59(Suppl. 2), S165-S172.

World Bank. (1993) World Development Report 1993: Investing in Health.

Zeitlin J, Govindaraj R & Chen L (1994). Financing Reproductive and sexual health services. In Population policies reconsidered: health, empowerment and rights.

Table 01. Methodology of relevant cost studies identified

References	Country	Intervention	Costing method	Sample number	Facilities	Cost estimates	Year of costs and currency
(Weissman et al . 1999b). Methods in full report (Weissman et al . 1999a)	Uganda	12 interventions contained in the Mother Baby Package (MBP)21	MBP: interviews with medical personnel on treatment provided, staff time and equipment. Client number s projected based on DHS and population estimates. Not estimated indirect or opportunity costs.	10 facilities	2 hospitals and 8 health centres. Government facilities in two districts	Total and average costs in hospitals and health centres. Breakdown by input category for hospital costs. No range provided.	1996 US$
(Levin et al . 2000)	Ghana, Malawi, Uganda	ANC, vaginal delivery, caesarean section, postpartum haemorrhage, eclampsia, post-abortion complications	Estimated direct costs: personnel time, drugs, equipment etc. and indirect costs: admin, maintenance, overhead, utilities. Service volume was obtained from facility records.	6 facilities and 20 private midwives.	3 public hospitals and 3 public health centres; 3 mission hospitals and 3 mission health centres, 20 private midwives with 2-3 years training in private nursing homes.	Unit costs of routine services and those relating to obstetric complications. Average for hospital and health centre.	Assumed 1998 US$
(Dmytraczenko 1998)	Bolivia	ANC, Delivery, Eclampsia, CS, Sepsis, abortion., episiotomy	Mother-Baby costing package as for Weissman 1999.	31 government facilities in 5 departments in Bolivia	9 facilities are tertiary hospitals: 4 maternity hospitals, 3 paediatrics hospitals, one maternal and child hospital and one general hospital. 8 are secondary level facilities and 14 health posts and health centres in rural and urban areas.	Unit cost of services (average for all facilities, no range provided)	Assumed 1998 in Bolivianos.
(Borghi et al. 2000b)	Argentina	Episiotomy	Cost of procedure based on questionnaire to 8 obstetricians in Argentina.	2 facilities one in wealthy province of Santa Fe and one in poorer province of Salta.	2 public maternity hospitals.	Unit cost of procedure broken down by resource input. Confidence interval provided.	US$ 1998
(Borghi et al. 2000)	Argentina	ANC, vaginal delivery, caesarean section	Top-down costing and direct allocation of costs. Source: hospital records. Joint costs were allocated based on interviews with personnel. Indirect costs and opportunity costs included.	4 facilities	2 health centres and 2 hospitals	Unit costs are disaggregated by inputs with confidence intervals based on inter-facility variability. Total, average and marginal costs provided.	US$1998
(Galvez et al. 2000)	Cuba			13 facilities	12 polyclinics and 1 maternity hospital
(Thinkamrop et al . 2000)	Thai-land			14 facilities	12 district hospitals and 2 general referral hospitals
(Jinabhai et al . 2000)	South Africa			6 facilities	5 health centres and 1 general referral hospital
(Anand et al. 1995)	India	Normal vaginal delivery/ANC and postnatal care.	Ingredients approach. Time utilisation study for staff allocation. Other resources allocated based on staff allocation to each activity.	One facility and home.	Primary health centre and home.	Total cost by resource input and unit cost. Marginal cost derived.	Rupees 1991
(Family Health International 1996)	Ecuador	ANC		10 facilities	Non-governmental clinics
(Suarez & Brambila 1994)	Mexico	ANC	Direct and indirect costs. Ingredients approach. Questionnaire to determine time allocation to departments of staff.	6 facilities	Health centres, private not-for profit.	Total and average costs. Total cost broken down by resource input.	US$ assume 1993-94.
(Mitchell M et al. 1997)	Mexico	ANC, postnatal care, ultrasound.	NA	2 facilities	NGOs
(Tinker & Koblinsky 1993)	Grenada	ANC	NA	36 facilities	7 health centres and 29 visiting stations	Average cost	US$ 1991
(Levin et al. 1999)	Bangladesh	ANC	Allocation of staff time, equipment, drugs and overheads to each activity.	2 facilities	‘rural sites’	Cost per birth averted.	US$ year not given.
(Rosenthal & Percy 1991)	Mexico	Ultrasound	Unable to obtain reference.
(Berman 1989, Berman et al . 1991)	Indonesia	Tetanus toxoid immunisation	Costs to the government not including opportunity costs. Expenditures on inputs.	‘routine health services ‘ not specified	Government facilities.	Cost per immunised case and per neo-natal death averted for routine versus crash programme of tetanus toxoid	US$ 1985
		MCH/FP visit incl. drugs and staff and capital.	No definition of MCH/FP or how costs were allocated.	6 facilities	2 health centre 4 subcentres	Cost per capita. Total cost broken down by input.	US$ 1981
(Fox-Rushby & Foord 1996)	The Gambia	ANC	Direct and indirect costs collected from interviews and records.	2 facilities	A mobile maternal outreach service compared to routine ANC a government health centre.	Total cost and average costs of ANC; cost per maternal death averted and per life year gained (LYG).	US$ 1991.
(Johnson et al. 1993)	Mexico and Kenya	Abortion: manual vacuum aspiration and sharp curettage	Rapid assessment methods including qualitative, cross-sectional, limited duration field observations and interviews with small non-representative samples	4 facilities in Kenya and 4 in Mexico	8 government hospitals	Cost per facility per intervention and broken down by input. Hospitalisation costs included.	US$ 1991
(Magotti et al . 1995)	Tanzania	Abortion: manual vacuum aspiration and sharp curettage	Questionnaires with medical staff. Not considered cost of medical instruments, transport, overheads, indirect or social costs.	1 government medical centre		Unit cost, cost of hospitalisation, labour cost, equipment cost and drug cost.	Tshs 1992

Note to table: NA: Not Available.

Table 02. Costs of antenatal care (ANC)

Country	Public Hospital		Public Health centre		Private maternity homea	At home (MC)
	Average cost (AC)	Marginal cost (%AC)	Average cost	Marginal cost (%AC)	Average cost
Bolivia (secondary)b	7.03 (incl. Lab on 1 st visit)	NA	7.13	NA	NA	NA
Bolivia tertiary level	13.87 (incl. lab on 1 st visit)	NA	NA	NA	NA	NA
Mexico	NA	NA	7.47c 4.74d	NA	NA	NA
Ecuadore	NA	NA	3.48	NA	NA	NA
Uganda public	4.18a 2.60f	1.48a (35) 1.25 (55)f	2.21a	1.03a (47)	1.39/3.42 (0.71/3.01)	NA
Uganda missiona	5.20	4.10 (79)	6.43	1.60 (25)	NA	NA
Malawi publica	5.48	4.44 (81)	3.23	2.18(67)	NA	NA
Malawi missiona	5.77	5.08 (88)	4.18	2.94 (70)	NA	NA
Ghana publica	5.45	2.59 (48)	3.17	1.94 (61)	3.02 (1.13)	NA
Ghana missiona	2.97	2.09 (70)	4.03	2.37 (9)	NA	NA
Argentinag	28.75 (24.40; 42.51)	7.90 (27)	33.46 (26.44; 31.06)	1.65 (5)	NA	NA
Cubah	12.15 (8.85; 15.46)	4.15 (34)	NA	NA	NA	NA
Thailandi	6.20 (5.33; 7.06)	1.46 (24)	NA	NA	NA	NA
South Africaj	9.05 (7.47; 10.62)	0.95 (10)	7.24 (5.78; 8.70)	0.42 (6)	NA	NA
Bangladeshk	NA	NA	17.83-92.74 per QALY gained or 30.12-78.29 per QALY gained	NA	NA	NA
Grenadal	NA	NA	25.13-29.92	NA	NA	NA
The Gambiam	NA	NA	21.32; 9.93	NA	NA	NA
Indian	NA	NA		NA	NA	4.63 (0.14)
Indonesiao	NA	NA	0.82-0.91	NA	NA	NA

Notes to table:

For all figures, the inflation adjustment factor based on the consumer price index. Source: Federal Bank of Minneapolis, the annual percentage change in inflation. CPI base year is chained: 1982-84=100

NA: Not Available.

^a Levin et al. 2000. Marginal cost considered as ‘materials’ (drug and supply costs). Private maternity homes: services provided by a private midwife. The range in Uganda is due to the fact that the private midwives may over-report their use of syndromic management of STDs, so the material costs were estimated with and without this component.

^b Dmytraczenko et al . 1998. 1US$=5.19 Bolivian Bolivianos in 01/01/ 1997 (http://www.oanda.com FX Converter). Assume average of 2 ante-natal visits per woman: average between first visit: US$10.02 and second visit: US$4.24.

^c Mitchell et al. 1997

^d Suarez & Brambila 1994

^e Family Health International 1996

^f Weissman et al . 1999b, Weissman E et al . 1999a

^g Borghi et al . 2000

^h Galvez et al . 2000

ⁱ Thinkamrop et al . 2000

^j Jinabhai et al . 2000

^k Levin et al . 1999. The range reflects comparison versus intervention groups in two districts each: the first range is for different frequencies of satellite clinics with addition of EPI services. The second intervention is for increased staffing and time open at health and family welfare centres in districts with satellite clinic intervention. The control is home delivery of services.

^l Tinker & Koblinsky 1993. From MotherCare Project, Laukaran, 1990.

^m Fox-Rushby & Foord 1996. Higher figure reflects the cost for the mobile maternal outreach service compared to traditional ANC in government health centre.

ⁿ Anand et al . 1995 Exchange rate for 1991/2: 1US$ = Rs 32.04. By a female multi-purpose worker.

^o Berman 1989. Higher cost reflects MCH/FP outpatient at subcentre, lower cost at health centre.

Table 03. Costs of Normal Vaginal Delivery

Country	Hospital		Health centre		Private maternity homea	At home (MC)
	Average cost	Marginal cost	Average cost	Marginal cost	AC (MC)
Bolivia (secondary)b	12.14 (17.53); 28.55c	NA	10.40 (14.07);	NA	NA	NA
Bolivia tertiary level	11.18 (16.76)	NA	NA	NA	NA	NA
Uganda public	33.90a 8.78d	4.31a (13) 1.01 (12 d )	2.71a	1.18a (44)	4.27 (3.10)	NA
Uganda missiona	32.89	5.28 (16)	15.31	4.48 (29)	NA	NA
Malawi publica	24.03	11.34 (47)	10.22	4.63 (45)	NA	NA
Malawi missiona	11.76	6.49 (55)	11.14	4.65 (42)	NA	NA
Ghana publica	14.60	7.57 (52)	3.17	1.94 (61)	12.75 (3.55)	NA
Ghana missiona	11.89	7.26 (61)	4.03	2.37 (59)	NA	NA
Argentinae	105.61 (70.81; 140.41)	5.41 (5)	NA	NA	NA	NA
Cubaf	21.32 (16.45; 26.20)	5.83 (27)	NA	NA	NA	NA
Thailandg	27.25 (22.01; 32.50)	5.54 (20)	NA	NA	NA	NA
South Africah	81.40 (74.49; 88.30)	5.38 (7)	NA	NA	NA	NA
Indiai	NA	NA	NA	NA	NA	4.42 (0.14)

Notes to table:

NA: Not Available.

^a Levin et al . 2000. Labour costs were not calculated for private midwives in Uganda because the information for calculation of net profit for these solo practitioners was incomplete.

^b Dmytraczenko et al . 1998. Delivery without episiotomy (delivery with episiotomy in brackets).

^c Rosenthal & Percy 1991

^d Weissman et al . 1999b, Weissman et al. 1999a

^e Borghi et al . 2000

^f Galvez et al . 2000. The confidence limits are based on variability in average costs between the health facilities in the sample.

^g Thinkamrop et al. 2000 Based on average of intervention and control hospitals.

^h Jinabhai et al . 2000

ⁱ Anand et al. 1995 Delivery conducted by a trained birth attendant.

Table 04. Costs of caesarean section

Country	Year	Average cost (AC)	Marginal cost (%AC)
Bolivia (secondary)a	1998 1991	67.63 incl. Lab; 57.11-106.23b	NA
Bolivia tertiary levela	1998	70.52	NA
Uganda public	1998	46.71c; 73.10d	38.39c (53) 9.87 (21)d
Uganda missionc	1998	86.48	53.15 (61)
Malawi publicc	1998	102.38	54.72 (53)
Malawi missionc	1998	61.39	44.12 (72)
Ghana publicc	1998	88.83	51.20 (58)
Ghana missionc	1998	55.60	38.02 (68)
Argentinae	1997	525.57 (452.56; 598.58)	80.28 (15)
Cubaf	1998	113.98(70.12; 157.83)	43.73 (38)
Thailandg	1998	83.00	46.14 (56)
South Africah	1998	140.60 (105.71; 175.48)	24.91 (18)

Notes to table:

NA: Not Available.

^a Dmytraczenko et al . 1998

^b Rosenthal & Percy 1991

^c Levin et al . 2000

^d Weissman et al . 1999b, Weissman et al . 1999a

^e Borghi et al . 2000. The confidence limits are based on variability in average costs between the health facilities in the sample

^f Galvez et al . 2000. The confidence limits are based on variability in average costs between the health facilities in the sample.

^g Thinkamrop et al . 2000. Based on average of intervention and control hospitals.

^h Jinabhai et al . 2000. The confidence limits are based on variability in average costs between the health facilities in the sample

Table 05. The cost of postpartum haemorrhage

Country	Year	Average cost (AC)	Marginal cost (% AC)
Uganda public	1998	50.63a; 35.44b	25.76 (51)a 3.98 (11)b
Uganda mission	1998	114.83a	52.26 (46)a
Malawi publica	1998	81.51	51.29 (63)
Malawi missiona	1998	67.13	46.31 (69)
Ghana publica	1998	92.94	36.48 (39)
Ghana missiona	1998	37.57	25.78 (69)

Note to table:

^a Levin et al . 2000

^b Weissman et al . 1999b, Weissman et al . 1999a Not specified if this is antepartum or postpartum haemorrhage.

Table 06. The cost of managing eclampsia

Country	Year	Average cost (AC)	Marginal cost (% AC)
Bolivia (secondary)a (Levin et al 2000.)	1998	39.88 (with lab)	NA
Bolivia tertiary level	1998	45.86 (with lab)	NA
Uganda public	1998	82.37b; 56.35c	13.33b (16) 8.89c (7)
Uganda mission	1998	159.66	19.50 (12)
Malawi publicb	1998	106.58	19.50 (18)
Malawi missionb	1998	52.66	21.07 (40)

Note to table:

NA: Not Available.
^a Dmytraczenko et al . 1998
^b Levin et al . 2000
^c Weissman et al. 1999b, Weissman et al . 1999a

Table 07. The cost of managing maternal sepsis

Country	Year	Average cost (AC)	Marginal cost (% AC)
Bolivia (secondary)a	1998	53.56	NA
Bolivia tertiary levela	1998	72.64	NA
Ugandab	1998	8.76	0.43 (5)

Note to table:

NA: Not Available.
^a Dmytraczenko et al . 1998
^b Weissman et al. 1999b, Weissman et al . 1999a

Table 08. The cost of Manual Vacuum Aspiration, brackets without hospital stay just procedure

Country	Year	Average cost (AC)	Marginal cost (% AC a )
Tanzaniab	1992	4.03 (2.02)	0.31 (8)
Mexicoc	1991	78.66 (43.12)	12.05 (15)
Kenyac	1991	3.52-6.27 (2.37-3.22)	1.20-1.27 (20-34)
Boliviad	1998	16.76; 28.56; 46.82	NA

Note to table:

NA: Not Available.

^a Marginal cost is presented as a proportion of the average cost including hospitalisation.

^b Magotti et al . 1995

^c Johnson et al . 1993. The range shows variability between hospitals included in the sample.

^d Dmytraczenko et al. 1998. The range is primary, secondary and tertiary level facilities respectively for just the procedure (not hospital stay).

Table 09. The cost of surgical (dilation and curettage), brackets without hospital stay just procedure

Country	Year	Average cost	Marginal cost
Tanzaniaa	1992	9.96 (5.03)	4.54 (46)
Mexicob	1991	94.82-282.31 (58.83-68.96)	10.78
Kenyab	1991	4.77-18.25 (2.70-5.45)	1.03-2.35
Boliviac	1998	51.06-51.83	NA

Note to table:

NA: Not Available.
^a Magotti et al. 1995
^b Johnson et al . 1993
^c Dmytraczenko et al . 1998. Range is for secondary to tertiary level facilities.

Table 10. The cost of managing post-abortion complications

Country	Year	Average cost	Marginal cost
Uganda public	1998	35.43a; 12.10b	19.43 (55)a
Uganda mission	1998	57.60	36.72 (64)
Malawi publica	1998	41.77	12.87 (31)
Malawi missiona	1998	29.95	18.49 (64)
Ghana publica	1998	66.46	43.55 (66)
Ghana missiona	1998	63.88	41.80 (65)
Boliviac	1998	89.02-104.05	NA
Boliviad	1991	95.26	NA
Nigeriae	1987	304.73	NA

Note to table:

NA: Not Available.
^a Levin et al. 2000
^b Weissman et al . 1999b, Weissman et al . 1999a
^c Dmytraczenko et al . 1998. Range is for secondary to tertiary level facilities.
^d Rosenthal & Percy 1991
^e Konje et al. 1992

Table 11. Annual projections of reproductive health costs (in $US billions) for developing countries, by funding source and type of cost, according to year

Source and cost	2000	2005	2010	2015
Total	17.00	18.50	20.50	21.70
Source
International donors	5.70	6.17	6.38	7.23
Developing country govts.	11.30	12.33	13.67	14.47
Type of cost
Family Planning	10.20	11.50	12.60	13.80
STD Prevention	1.30	1.40	1.50	1.50
Basic RH22	5.00	5.40	5.70	6.10
Research, data, policy analysis	0.50	0.20	0.70	0.30

Table 12. Trends in Bilateral and Multilateral Maternal health expenditure (constant 1990 US$ (%))

	1986a	1987 a	1988 a	1990b
Family Planning	470.1	442.9	519.2	936
Other maternal	169.8	156.6	187.8	360
TOTAL direct and indirect	1296.3	1218.2	1432.1	1929

Notes to table:

^a Howard 1990. Figures for 1988, indicated that maternal health was 12% of total direct and indirect health expenditure for bilateral donors and 15% for multilateral aid. For family planning the figures were: 37 and 36%. These proportions were used here in the calculations for 1986 and 1987. FP and maternal health limited to family planning, community-based maternal care, referral facilities for the complications of pregnancy, and communication and transport systems to support referral cases. Direct and indirect includes all programmes that influence maternal mortality and morbidity.

^b Rannan-Eliya et al. 2000. Figure for family planning classified as ‘Population’ in original text which includes the collection and analysis of demographic survey data. Total direct and indirect includes: reproductive health (excluding communicable disease, chronic disease and health services).

Table 13. Trends in USAID assistance to the health sector in developing countries (constant 1995 US$)

	1986	1987	1988	1990	1992	1995
Safe Motherhood activities	321.8	304.3	297.6	NA	NA	NA
Non-family planning component	43.1	22.8	38.6	30	70	30

Note to table:

1986-1988 (Howard 1990).
1990-1995 ( Potts et al. 1999).

Table 14. Trends in domestic expenditure on maternal health as a percentage of total health expenditure

Countries	% to maternal health
	1983	1982	1988	1990	1992	1994/5	1997	1998
Sri Lanka		13					4-12a
Malawib	4
Egyptc							8
Bangladeshd						19
Indiae					11
Ugandaf								7
Papua new Guineag			8-9(1987)
Total developing countriesb				4-17
Latin American & the carribeanb				13

Notes to table:

^a Rannan-Eliya et al. 2000. Estimates that maternal health alone represents 1% of national health expenditure, but if we include other components of reproductive health: infant and child care, family planning services, STDs is 4%, if we consider 15% of hospital inpatient care, 6% of hospital outpatient care, 6% outpatient curative care, 6% other registered medical care professionals, 2% traditional medical advisors, 6% medical goods supplied to outpatients, then the percentage increases to 12.4%

^b Howard 1990. For Malawi this is based on a non-references ‘report’ and expenditure is attributed to ‘maternities and ‘dispensary maternities’

^c Rannan-Eliya et al . 2000, Rannan-Eliya et al . 1997.

^d Merrick 1999. Health Economics Unit estimates suggest that total funding for the health sector was $855 million in 1994/95, equivalent to $7.1 per capita or 3.1% of GNP. Expenditures on MCH/FP were estimated at $1.41 per capita.

^e Anand et al. 1995. Cost of MCH as % of total cost of primary health care.

^f Weissman et al . 1999b, Weissman et al. 1999a. It was found that the Ugandan government currently spends about US$ 0.50 per capita on maternal and newborn health care, and we assumed a $7 per capita total health expenditure (Sentumbwe, http//:www.insp.com/The Structural Adjustment programme and the health Sector in Uganda).

^g Mitchell et al . 1991. Based on government and church facilities: health centres and subcentres.

Table 15. 3 stereotype health systems

	Public sector plays the predominant role in financing and provision	Mixed public-private roles in financing and provision	Strong private sector presence and reliance on market mechanisms
Finance:	General tax revenues, donor funds, user fees	General tax revenues, earmarked social insurance funds	Out-of-pocket payments, social health insurance funds

SOURCE: Krasovec & Shaw 2000.

Table 16. Macro-level Models of Health care Financing

Country/ study	Financing of MCH	Macro implications	Maternal outcome
Sri Lanka	· Government funds 48% of primary care services and 87% of hospital services. · The private sector funds 52% of primary care services. Only 13% of hospital services are financed by the private sector due to the failure of the insurance market to provide catastrophic health insurance. Less than 2% of total health sector financing is from health insurance, and similarly population coverage for health insurance has not increased beyond 2% (Hsiao 2000). · A recent study reports that public financing ac-counts for more than 90% of all funding for MCH services, which are mostly prenatal and postnatal care, despite household’s willingness to pay for out-patient services (Rannan-Eliya et al . 2000).	· Expansion of service provision during the 1930-40s was financed by increasing taxation of the plantation sector. · 1950-70s public services deliver an increasing volume of services by halving unit costs, hence, using personnel and infrastructure even more intensively (Hsiao 2000)	· 96% of women given birth in a hospital 99.6% antenatal coverage · 90% maternal tetanus immunisation · 0.8/1000 maternal mortality 1999
Egypt (Rannan-Eliya et al . 2000)	· Government services are subsidised and provided largely free to all citizens. · Health Insurance Organisation (HIO), established 1964, a compulsory social insurance agency levying payroll contributions on formal sector workers and their employers. Coverage does not extend to dependents. Premiums range from 2-5% of assessed salaries. It also receives ad hoc subsidies from the Egyptian government: so funded part social insurance, part general revenues (50-50%). · A separate HIO program was introduced in 1993, the Student Medical Insurance Programme (SMIP), financed by a mix of individual premiums by enrolled students, earmarked cigarette tax and general revenue (76% in 1994/95 and 14% by premiums). · HIP runs its own service delivery system: 31 hospitals in 1995 and a large number of outpatient clinics.	· Restricted coverage of HIO 9.7% of the population	· 28% of mothers receive regular antenatal care · 43% of mothers received two doses of tetanus toxoid immunisation before giving birth · 1/3rd deliveries took place in a health facility with trained medical personnel
Bolivia (http//:www.phpr.com/publicat/hrps/finan.html)	· Local governments are required to use 6% of the federal tax dollars they receive to support a maternal and child health insurance fund that provides basic entitlements to primary and curative care (Krasovec & Shaw 2000). · Bolivia’s National Mother and Child Health Insurance Program: introduced in 1996; provide free essential medical care for women of child-bearing age, newborns and children up to five years old. · Covers selected priority health needs such as birth and antenatal care. Program financing comes from the municipalities and is earmarked for reimbursing providers for medicines, sup-plies and hospitalisation.	· Reimbursement rates do not cover the actual cost of drugs, supplies and hospitalisation. Facilities are left short of operating cash for drugs and other supplies. · Facilities are not reimbursed by SNMN for personnel and other indirect costs which are a large proportion of total cost especially in the tertiary facilities	· Use of all covered services increased, at a much faster rate than those services which were not covered (18 months prior and after introduction): · Increase 16% to 39% for prenatal visits · Births increased from 43% to 50% · According to patient exit interviews, new users had previously only received healthcare at home.

Table 17. The role of NGOs in the financing of Maternal Health Care Services

Country /study	Financing of MCH	Scope of services provided	Maternal outcome
Malawi (Krasovec & Shaw 2000)	· The government works closely with the Christian Health Medical Association (CHAM) subsidising approx. 15% of the recurrent cost of the mission facilities in return for provision of a range of FP services and IEC	NA	NA
Bolivia (Mintz & Savedoff 2000)	· PROSALUD began in 1985 as a non-profit organisation operating in facilities provided by the municipal government but managing its own and operations. · Financed from a system of cross-subsidies, where the middle class population of certain clinics would subsidise the lower prices charged in clinics in areas with a lower standard of living. · The majority of resources came from users’ low cost payments and the rest from outside funding such as USAID. Financed 70% by revenues in 199423.	· 34 health centres · 1 referral hospital · 1 child development centre Services cover a population of 400,000 in 6 regions of the country.	NA
Brazil (Krasovec & Shaw 2000 )	· Governments subsidises non-governmental organisations or traditional medical practitioners to deliver reproductive health services to poor families. · About 30% of the municipal governments in Brazil provide funding to the Sociedade Civil Bem Ester Familiar No Brasil (BEMFEM) and NGO that provides services in public-sector health posts and training to public sector health personnel, as well as operating its own clinics providing a broad array of reproductive health services.	· Concentrated in poorest regions of the country	NA
Guatemala (Nieves & La Forgia 2000)	· Large-scale government contracting of NGOs to extend basic health services to poor populations in Guatemala · The programme to extend coverage of basic services (PECSB) aims to extend coverage and reach poor, rural, indigenous populations, who had no regular access to modern health services. · The government funds NGOs to provide and administer these services. The payment covers the direct cost of the basic package plus administrative expenses and expenses related to institutional strengthening. In 1999, the average per capita payment was approx. $6.25.	· The programme started at the end of 1997 and by the end of 1999 · The total number of contracted NGOS were 89. · The level of public spending in cove-rage by NGOs in-creased from US$ 1.7 million in 1997 to US$ 12.4 million in early 2000. · The population that NGOS were contracted to serve reached a total of 3.5 million in 1999.	Substantial increase in coverage and quality of Essential Obstetric care (EOC) · Increased hospital based delivery rates · Increase in met need (greater % of women with complications seek care)

Table 18. Community-level financing programmes

	Aim	Financing method	Issues	Outcomes
Nigeria (Chiwuzie et al . 1997)	Cost recovery system for emergency transport to health facilities for pregnant women or other funds they might need	A loan fund: donations were made from the heads of 13 clans (65%) and the PMM team (35%). · Women in need of financial assistance for problems relating to pregnancy or delivery an apply · Payback loan with interest of 2%.	There was a 93% repayment rate. Need higher interest rate in future.	· 30 pregnancy-related loans administered per month.
Sierra Leone (Thuray et al. 1997)	Cost recovery system for drugs	· Drug provision on monthly basis obtained directly from commercial supplier in Amsterdam rather than going through the government · Charges to patients on basis of full cost of obtained drugs, including handling and transportation and a mark-up of 85% to allow for inflation and less than full cost recovery · The patients could receive treatment without advance payment although the family was encouraged to pay all fees before the family was discharged.	· Prices were lower than private pharmacy and hospital pharmacy. 57% cost recovery rate during the study period.	· The case fatality ratio for women in project area feel from 12% in 1992 to 4% in 1993 compared to 13-11% in the non-project area.
Sierra Leone (Fofana et al . 1997)	Community loan fund	· 2 chiefdoms were mobilised to establish funds. · The local leadership imposed levies on the adults of the community: 20 cents (1992) for each male and 10 cents for each female. · The loan fund was managed by the village development committee · In an emergency women could receive treatment immediately and at discharge a bill provided. If she was unable to pay she could take it to the loan fund committee. Payment was later enforced.	NA	· Increase in utilisation compared to non-intervention area.
The Gambia (Fox-Rushby & Foord 1996)	Form of insurance paid du-ring ANC visit and ensuring free access to health services that followed	· Each pregnant woman was paid US$3.16 (1992) to the midwife at, or soon after the first consultation. If the woman did not pay she was responsible for her own expenses	· 82% of hospital and health centre drug costs for maternity care were recovered in theory	· Very high insurance uptake (90%)
Tanzania (Krasovec & Shaw 2000)	Community health fund in Igunga District	· Cost sharing by house-holds along with government subsidies for a health card en-titling households to basic reproductive health and other health services at rural health centres.	· Is now expanding to 6 other districts	NA
Mali ( 63 )	An emergency referral and evacuation system for obstetric care	· 30% financing from district level, 30% from the community and 30% from evacuees who pay user fees	NA	NA
Rwanda (Krasovec & Shaw 2000)	A prepayment scheme covering preventative and curative care provided by nurses in health centres, essential drugs and hospital cover and ambulance transfer to hospital in case of obstetric emergencies	· Enables farmers to access care, when they would typically forgo care in times of need due to the lack of resources to pay (except at specific times: 2 post-harvest periods)	NA	NA