R.A. Abdus-salam1, 3, T. Mark2 , A.D. Agboola3 , and T. Babawarun4

  1. Department of Obstetrics and Gynaecology, University of Ibadan, Oyo, Nigeria.
  2. University College Hospital, Ibadan Oyo state, Nigeria. 
  3. Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Oyo state, Nigeria. 
  4. Centre for Population and Reproductive Health, University of Ibadan, Ibadan, Oyo, Nigeria.


Background: Universal health coverage and healthcare financing for maternal health services are essential for quality care, prevention of complication and a reduction in maternal morbidity and mortality. Objective: To evaluate the modes of healthcare financing for antenatal and delivery care among pregnant women in a tertiary health facility in SouthWest Nigeria. 

Methods: This is a four-year retrospective review of maternal healthcare financing models adopted by pregnant/postpartum women at the antenatal clinic and labour/delivery unit. Data for health financing in antenatal booking clinic for a four-year period from 2016-2019 and labour & delivery for a two year period from 2018 and 2019 were reviewed. The information collected were – number of women that paid out-of-pocket for services, number of women that paid for services using health insurance and other means of payment during the period. Data were analysed using SPSS version 23. 

Result: A total of 7,129 women accessed antenatal care services during the period under review. About 58.9% of the women paid for antenatal care services out-of-pocket, 36.6% were covered under the health insurance (social and private health insurance). A total of 2,881 women accessed delivery services at the health facility. About 66.4% of the women paid out-of-pocket for both caesarean section and vaginal delivery. Prepaid health insurance was used by about 31% of the women. 

Conclusion: Health insurance has been available for over a decade; however prepaid healthcare financing model remains less popular. Out-of-pocket payment constitutes the predominant mode of healthcare financing for maternal healthcare among pregnant women at the tertiary health facility. The out-of-pocket payment exposes the pregnant women and her family to financial burden and catastrophic spending especially in obstetric emergency.

Keywords: Healthcare financing, Out-of-pocket payment, Antenatal care, Health facility-based delivery


Dr. R.A. Abdus-salam 

Department of Obs. and Gynae., 

College of Medicine, 

University of Ibadan/ 

University College Hospital, 

Ibadan, Oyo state, 




Universal Health Coverage (UHC) can simply be described as access to quality healthcare free of financial burden. UHC is defined as health coverage in which individuals and communities receive health services needed without suffering financial hardship.1 The goal of UHC is to increase equity in access, quality of health care services and reduce the financial risk associated with it.2,3 With UHC, people are able to access quality healthcare services for prevention of disease or death, health promotion, treatment of diseases and other health problems.

Access to quality antenatal care and utilization are essential for the prevention of maternal morbidity, mortality and ensuring successful pregnancy outcomes; there have been recommendations by the World Health Organization (WHO) on health system interventions to improve utilization of antenatal care.4 Antenatal care utilization is affected by availability, accessibility, place of residence, cost of care, household income, occupation, employment status and socioeconomic status among others.5–8 Availability of funds for birth related expenses and complications is a vital element in obstetric care and it constitutes one of the elements of a birth preparedness and complication readiness plan.9 Healthcare financing is an important determining factor in the provision and utilization of quality antenatal care service.

According to the World Health Organization (WHO); in the health systems framework, there are key components necessary to ensure optimal function of a healthcare system and service delivery.10 These include leadership and governance, health information, health financing, essential medical products and technologies, human resources for health and service delivery. These form the building blocks for healthcare access, coverage, quality and safety with the ultimate goals of improved health, responsiveness, social and financial risk protection; and improved efficiency of healthcare systems.

Health care financing involves the means by “funds are generated, allocated and utilized for health care”. The functions of health systems financing include revenue collection, pooling of resources and purchase of services.11 The mechanisms of healthcare financing in Nigeria consists of a combination of tax-revenue financing, OOP payments, donor funding and health insurance.11 In tax revenue type health financing, the funds are tax-based, generated through taxation and government revenues at the local, state and federal government levels. OOP involves payment for healthcare services at the point of care; it accounts for the highest health expenditure in Nigeria. The social health insurance involves health care system financing through contributions to an insurance fund operating within government regulations. Lastly, donor funding constitutes financial assistance contributed to the healthcare system as support for health development.11 Payment for use of health care constitutes one of the mechanisms for health care financing; and it is clear that for any healthcare system to function, health financing is an important determinant of access and coverage. This will ensure improved healthcare, reduce or eliminate financial barriers and minimize inequalities in healthcare service delivery. According to Kutzin, for any country to achieve health coverage for her populace, compulsory or public funding is needed.12 The implementation of UHC in various regions has demonstrated positive impacts on access to health care and service delivery. These include increased utilization of health care service among poor previously uninsured individuals.13–15 Health insurance program is associated with a reduction of out-of-pocket (OOP) payment and catastrophic health expenditures.16

The National health insurance scheme (NHIS) was established in 1999 and officially launched in 2005; but it is poorly implemented and mostly underutilized. In the National demographic health survey 2018, health insurance coverage was low; only 3% of the respondents had health insurance coverage, mostly employer-based; and it is limited to the urban areas. Eleven percent of women and 12% of men with more than secondary level of education have employer-based insurance coverage.17

The NHIS in Nigeria was introduced to enhance the plan towards ensuring UHC for all. However, since its implementation; the utilization and coverage of the health insurance scheme has been less than optimal and disappointing. In Nigeria, health care system financing has been largely out of pocket payment which has impoverished families and kept them in the vicious circle of poverty and health insurance only covers less than 5% of the populace.18,19

With low health insurance coverage in Nigeria; health insurance coverage among pregnant women will be poor thus impairing access to antenatal care and prompt emergency obstetric care. Pregnant women and children constitute the vulnerable group in poor health systems. According to Browne and colleagues, the utilization of the maternal, neonatal and child continuum health care service in Ghana depended largely on the maternal health insurance status.20 Healthcare financing is an important component of birth preparedness and complication readiness. In obstetric emergency, lack of adequate funds for healthcare plays a vital role in all the level of delays contributing to maternal mortality.21 To address the appalling health indices in Nigeria; that is to reduce maternal and perinatal morbidity and mortality, there is an urgent need to review maternal health financing in order to achieve universal access to maternal health care.22 

This study aims to evaluate the modes of healthcare service financing for antenatal and delivery care. The findings of the study will shed light on the state of health care financing and the trend in health financing for maternal care.