Social health protection and maternal health: Conflict in policies to achieve millennium development goals

Social protection has long been recognized as necessary to reduce inequities and to provide dignity for the beneficiaries through their affordable contributions as compared to relying on savings or charity for health care and through other contingencies. Mechanisms to ensure safe pregnancy and safe motherhood are an integral part of social protection within the social security systems developed for the formal labour sector. The lack of mechanisms for the informal economy is seen as a serious gap in extending coverage. The extension of coverage in this population has been slow, but the provision of care for pregnant women and infants is perceived as an attraction to sustained affiliation in community based or micro-health insurance schemes. Pregnancy is usually a positive and anticipated health condition, and access to care through a regular small contribution to ensure a safe outcome is appreciated, especially when the care includes a comprehensive range of services, including normal and Caesarean section deliveries in hospital without additional charges. The growth of social health protection coverage may now be hindered by what should be a positive development intervention. The Millennium Development Goals (MDGs) introduced through the United Nations initiative in 2000 include MDG 5: to improve maternal health, with targets to reduce the maternal mortality ratio by 2015 for each country. The large variation in these ratios across countries indicates that indeed most maternal deaths can be prevented with appropriate care. However, some countries have very low achievement in MDG 5, and there is now pressure on governments to provide deliveries free of charge. Governments are finding that they can only afford free deliveries for the poorest while a declaration of the "free delivery" policy made by national authorities leads to expectations among all population groups. The attractiveness of joining the social health insurance schemes in the informal economy population may be questioned in this process, leading to a potential conflict between the free delivery policy and the extension of social health protection coverage with comprehensive benefits in vulnerable populations.