Community based maternal health fund: a case study from women ‘s group initiative in Awbare woreda of Somali region of Ethiopia

INTRODUCTION

Access to maternal and newborn health services in most poor countries has been impeded by financial barriers and there has been increased attention for the mobilization of local resources to improve access to services.^1,2 The major causes of maternal and newborn mortality in developing countries are the three delays in seeking, accessing, and receiving appropriate and quality care.^3,4 Community funds using various modalities in the context of safe motherhood initiatives have been found to reduce delays in care seeking particularly to cover transport costs and increase the utilization of health facilities for delivery and emergency obstetric care.^5-8 This study described community based maternal health fund set up by the women’s group in a rural area of Somali region of Ethiopia.

CASE REPORT

This is organized and presented along the three major themes: Initiation of the fund, management of the fund, linkage with the health system and outcome of intervention.

Initiation of the fund

This community fund was established and being managed by an indigenous voluntary women’s group called ‘Umulgargar’ in Somali language which means ‘Save mothers at risk association’. The process for the establishment of the community fund started in 2016 as a result of financial constraints faced by some pregnant women admitted at the main health centre in the Awbare woreda (district). Some of the pregnant women with obstetric complications were said to have refused to go to the referral hospital and opted to go back home because they lacked money to support their care at the referral hospital. Some other women following delivery were noticed not to have any means of transporting themselves back to the villages where they lived, while others were noticed not to have any change of clothing for themselves and/or their babies after delivery. At that time, the coordinator of the women’s group who worked at the health center as community midwife along with her other colleagues usually contributed money or solicited funds from the community members to support these group of needy women. After repeated experiences, these women who were usually involved with contributing money decided to mobilize more women from the communities to form the women’s group.

During their planning meetings, the members described priority problems and agreed on the need to establish a local fund that would be easily accessible in emergencies for poor pregnant women in the communities. At subsequent group meetings, the management strategies for funds, and the nature and frequency of contributions were discussed. The agreement reached was to use the funds to support poor pregnant women by providing money to either defray hospital bills when referred to the hospital, support transport fare back home after delivery or to provide basic households items including clothing for those who need them.

Management of the fund

The women’s group established the management committee made up of seven people selected among themselves and responsible for the collection, banking, disbursement and record keeping. The group didn’t receive any seed money or take off grant or guidance on fund management from any organization. The funds were raised exclusively through monthly contribution from the members and contributions received from other members of the communities. At the start, the management and operation of funds was entirely at group’s discretion, however, over time procedures were established as set out in the bye law developed by the group. The group has been able to build the trust among themselves and within the community. This has helped in ensuring that the financial contribution has been sustained since the inception in 2016.

The group initially had a total membership of 50 people in Awbare, the main town in the woreda when it was established, however, has grown to 195 women with members from additional four kebeles (sub districts). The uniqueness of the fund is that the women group members themselves do not benefit from the fund.

The group members agree on how the funds are to be disbursed during their monthly meetings. The funds which were initially set up mainly to provide financial support to women for emergency referral and transportation back home from the health centre has been extended to support mothers who are hosted at the maternal waiting home located within the health centre.

The fund is targeted at supporting mothers from poor /indigent households during pregnancy and delivery identified by using culturally based criteria including household assets, living conditions etc.

Linkages with the health system

The group is known and recognized in the woreda and work closely with the health system. This has also helped to build the confidence of the pregnant women they support in the health system. Pregnant women referred from the health centre are provided with free ambulance service to transport them to the hospital by the health centre/woreda health office, while the group provides financial support for the women’s basic needs during the hospital stay. In addition, the head of the health centre is a member of the management board of the group, this ensures government’s awareness of the group’s activities.

Outcome of intervention

Since the establishment of the community-based fund in 2016 and the study period in October 2021, the financial records showed that there was an average of 175 regular monthly contributors and most of these were members of the women’s group. The average monthly contribution was 13,000 ETB ($282) and total of 754 pregnant and lactating mothers have benefitted from the fund (403 supported during referral to the hospital; 284 provided with transport fare and basic household commodities after delivery and 67 hosted at the maternal waiting homes and provided with food and transport fare). Each of the beneficiaries received between 1,000ETB ($21.7) and 1,500ETB ($32.6).

DISCUSSION

This study illustrates participative community-based initiative to address financial barriers to utilization of maternal and newborn health including emergency obstetric services by poor pregnant mothers in the communities. Various modalities of community financing program have been used in the context of safe motherhood initiatives to reduce delays in care seeking, particularly to cover emergency referral services, transport costs and improve access and utilization of maternal and newborn health services.^2,5-8 Most of the documented studies on community financing required community members to contribute their own cash either upfront or as a revolving approach where users of the loan had to reimburse the fund.^9-12 This funding scheme is unique because the women’s group members who set up the fund and the main contributors to it are not part of the beneficiaries. The motivation to set up the fund was the group’s commitment to volunteer their time and resources as a contribution to their community to improve maternal and newborn health outcomes.

The community fund in this study was self-initiated by a group of local women who also established their own management structures using their indigenous ideas and experience. This is unlike most initiatives for obstetric emergency and maternal and newborn health emergency schemes which were facilitated by government or non-governmental organization (NGO) or developed as a part of a project implemented and set up in collaboration with the community.^9-12 This uniquely demonstrated community ownership and leadership of the programme at all stages from establishment, fund management and utilization decisions built by consensus within the group. This allowed for flexibility and adaptation to local context while supporting local skill and capacity building for financial management.

In addition to being community initiated, the Umulgargar did not receive any grant, seed money or start up fund for setting up this community-based funding. This is unlike most studied community funds where seed money or start-up cost was provided to the community groups to initiate or facilitate the process.^9-13

A notable benefit of this community fund is the flexibility and wider application of the funds to meet other emerging local needs of the women in the community as determined by the group. This is unlike most other community funds which are usually restricted to support emergency referral or other specific goals of the programme. Part of the funds raised by the scheme is used to support mothers in the maternal waiting home by providing them with food and transportation to return home. This is essential in this region where many people live more than 10 km from the nearest health facility with the accompanying high home delivery rates. Supporting mothers by improving birth preparedness and ensuring they deliver in the health facility is key to improving maternal and child outcomes. Several studies have demonstrated the contribution maternal waiting homes to improving pregnant women’s access to quality and timely maternal health care services, especially for women with high-risk pregnancies or those who live in remote areas.^13-17 However, studies identified lack of family and community support, access to food during their stay and lack of transportation after delivery as key barriers to the use of maternal waiting homes (MWHs).^17-19 This community fund has been able to successfully address some of these barriers. Scaling up of this innovation in other MWHs in the region and other districts in Ethiopia has the potential to improve the use of the MWHs and increase the rates of women who deliver in health facilities and contribute to reducing maternal and newborn morbidity and mortality.

The financial support provided by the group to pregnant mothers from poor households could also contribute to empowering the women and reducing the effect of gender on the utilization of maternal and child health services in the region. Financial constraints related to gender imbalance is known to prevent women from seeking needed medical services for themselves or children.^20,21 The awareness of these women about the opportunities provided by this community fund may actually encourage many more pregnant women from poor households whose main reason for not seeking health care is lack of finances to seek health care services.

This community fund which is targeted at the poor has the potential to overcome one of the major limitations of other community funds in meeting the need of the poor. Many of such schemes, though set up to meet the needs of women from poor households, often do not achieve this aim. Studies in rural Nepal and Mozambique and a systematic review on various modalities of community fund reported that only community members who are able to meet the mandatory financial contribution joined the group and benefited from the programs and only those trusted to be able to pay back are provided the loans.^9,22,23,24 Hence many women from extremely poor households who are most in need of support are marginalized and prevented from joining and limited their access to the emergency funds because they lack the resources to meet the mandatory requirements.

Another major concern identified in community-based funding schemes is sustainability. Inconsistent contribution by members, and modality for administration of the funds have been identified as factors that affect both the effectiveness and the sustainability of community fund schemes.^2,3,9,22,25 Many community funds were set up to provide loans and many beneficiaries were not able to repay on time or defaulted in payment resulting in collapse of the scheme.^9,22,25 Other schemes were initiated by external partners as part of community project and these usually have the tendency of not being sustained beyond the life of the project due to the withdrawal of the external support for funding or management.^2,3,9,22,25 The community fund described here has the benefit of not being set up as a loan scheme, exclusively making use of community resources with no external fund or grant to mobilise funds and also being locally managed with in-built mechanisms for accountability. All these increase the likelihood for sustainability and long-term impact on the community. The increase in the number of contributors to the fund and expansion into more communities within the few years of its establishment is a testament to this.

CONCLUSION

The study demonstrates how community members are able to mobilize local resources to develop community solutions to identified local problems through active participation and commitment. Scaling up such innovative community initiated, and managed funds has great potential to improve access to services and improve maternal and child health indices.

ACKNOWLEDGEMENTS

The authors would like to thank Nimco Abdi Osman the coordinator of the women’s group (Umurgargar) in Awbare woreda of Ethiopia and other group members who provided the details about the group.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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