{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,28]],"date-time":"2026-07-28T11:24:54Z","timestamp":1785237894484,"version":"3.55.0"},"reference-count":37,"publisher":"Public Library of Science (PLoS)","issue":"3","license":[{"start":{"date-parts":[[2024,3,13]],"date-time":"2024-03-13T00:00:00Z","timestamp":1710288000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000865","name":"Bill and Melinda Gates Foundation","doi-asserted-by":"publisher","award":["OPP1169546"],"award-info":[{"award-number":["OPP1169546"]}],"id":[{"id":"10.13039\/100000865","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>The concept of universal health coverage (UHC) encompasses both access to essential health services and freedom from financial harm. The World Health Organization\u2019s Maternal Newborn Child and Adolescent Health (MNCAH) Policy Survey collects data on policies that have the potential to reduce maternal morbidity and mortality. The indicator, \u201c<jats:italic>Are the following health services provided free of charge at point-of-use in the public sector for women of reproductive age<\/jats:italic>?\u201d, captures the free provision of 13 key categories of maternal health-related services, to measure the success of UHC implementation with respect to maternal health. However, it is unknown whether it provides a valid measure of the provision of free care. Therefore, this study compared free maternal healthcare laws and policies against actual practice in three countries.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods and findings<\/jats:title>\n<jats:p>We conducted a cross-sectional study in four districts\/provinces in Argentina, Ghana, and India. We performed desk reviews to identify free care laws and policies at the country level and compared those with reports at the global level. We conducted exit interviews with women aged 15\u201349 years who used a component service or their accompanying persons, as well as with facility chief financial officers or billing administrators, to determine if women had out-of-pocket expenditures associated with accessing services. For designated free services, prevalence of expenditures at the service level for women and reports by financial officers of women ever having expenditures associated with services designated as free were computed. These three sources of data (desk review, surveys of women and administrators) were triangulated, and chi-square analysis was conducted to determine if charges were levied differentially by standard equity stratifiers. Designation of services as free matched what was reported in the MNCAH Policy Survey for Argentina and Ghana. In India, insecticide-treated bed nets and testing and treatment for syphilis were only designated as free for selected populations, differing from the WHO MNCAH Policy Survey. Among 1046, 923, and 1102 women and accompanying persons who were interviewed in Argentina, Ghana, and India, respectively, the highest prevalence of associated expenditures among women who received a component service in each setting was for cesarean section in Argentina (26%, 24\/92); family planning in Ghana (78.4%, 69\/88); and postnatal maternal care in India (94.4%, 85\/90). The highest prevalence of women ever having out of pocket expenditures associated with accessing any free service reported by financial officers was 9.1% (2\/22) in Argentina, 64.1% (93\/145) in Ghana, and 29.7% (47\/158) in India. Across the three countries, self-reports of out of pocket expenditures were significantly associated with district\/province and educational status of women. Additionally, wealth quintile in Argentina and age in India were significantly associated with women reporting out of pocket expenditures.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>Free care laws were largely accurately reported in the global MNCAH policy database. Notably, we found that women absorbed both direct and indirect costs and made both formal and informal payments for services designated as free. Therefore, the policy indicator does not provide a valid reflection of UHC in the three settings.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0299249","type":"journal-article","created":{"date-parts":[[2024,3,13]],"date-time":"2024-03-13T17:38:37Z","timestamp":1710351517000},"page":"e0299249","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":2,"title":["Validating the implementation of an indicator reporting policies and laws on free public maternal health-related services in the era of universal health coverage: A multi-country cross-sectional study"],"prefix":"10.1371","volume":"19","author":[{"given":"Magdalene A.","family":"Odikro","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ernest","family":"Kenu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Richard M.","family":"Adanu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Delia A. B.","family":"Bandoh","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mabel","family":"Berrueta","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Suchandrima","family":"Chakraborty","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9880-2591","authenticated-orcid":true,"given":"Jewel","family":"Gausman","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nizamuddin","family":"Khan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ana","family":"Langer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carolina","family":"Nigri","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Veronica","family":"Pingray","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sowmya","family":"Ramesh","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Niranjan","family":"Saggurti","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paula","family":"V\u00e1zquez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4925-869X","authenticated-orcid":true,"given":"Caitlin R.","family":"Williams","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1440-4722","authenticated-orcid":true,"given":"R. Rima","family":"Jolivet","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2024,3,13]]},"reference":[{"key":"pone.0299249.ref001","author":"WHO","journal-title":"SDG Target 3.8 | Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all [Internet]."},{"key":"pone.0299249.ref002","author":"WHO","journal-title":"Universal health coverage (UHC) [Internet]."},{"key":"pone.0299249.ref003","article-title":"Global indicator framework for the Sustainable Development Goals and targets of the 2030 Agenda for Sustainable Development Sustainable Development Goal indicators should be disaggregated, where relevant, by income, sex, age, race, ethnicity, migratory status, disability and geographic location, or other characteristics, in accordance with the Fundamental Principles of Official Statistics","journal-title":"1 Goals and targets (from the 2030 Agenda for Sustainable Development) Indicators."},{"key":"pone.0299249.ref004","doi-asserted-by":"crossref","first-page":"152","DOI":"10.1016\/S2214-109X(17)30472-2","article-title":"Monitoring universal health coverage within the Sustainable Development Goals: development and baseline data for an index of essential health services.","volume":"6","author":"DR Hogan","year":"2018","journal-title":"Articles Lancet Glob Health [Internet]."},{"key":"pone.0299249.ref005","journal-title":"UHC explained: Women, children and adolescents as a UHC priority [Internet]"},{"issue":"5","key":"pone.0299249.ref006","doi-asserted-by":"crossref","first-page":"398","DOI":"10.2471\/BLT.16.170431","article-title":"The Global strategy for women\u2019s, children\u2019s and adolescents\u2019 health (2016\u20132030): a roadmap based on evidence and country experience.","volume":"94","author":"S Kuruvilla","year":"2016","journal-title":"Bull World Health Organ [Internet]."},{"key":"pone.0299249.ref007","year":"2019","journal-title":"PMNCH | Universal Health Coverage: Are we losing our way on women\u2019s and children\u2019s health? 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A conceptual framework for understanding indicator validation","volume":"15","author":"L Benova","year":"2020","journal-title":"PLoS One [Internet]."},{"issue":"3","key":"pone.0299249.ref015","doi-asserted-by":"crossref","first-page":"310","DOI":"10.1016\/j.ijgo.2011.09.007","article-title":"User fees and maternity services in Ethiopia","volume":"115","author":"L Pearson","year":"2011","journal-title":"International Journal of Gynecology & Obstetrics"},{"issue":"1","key":"pone.0299249.ref016","doi-asserted-by":"crossref","first-page":"147","DOI":"10.1093\/oxrep\/grv019","article-title":"Measuring progress towards universal health coverage: with an application to 24 developing countries.","volume":"32","author":"A Wagstaff","year":"2016","journal-title":"Oxf Rev Econ Policy [Internet]."},{"issue":"1","key":"pone.0299249.ref017","first-page":"1","article-title":"Maternal perceptions of the quality of Care in the Free Maternal Care Policy in sub-Sahara Africa: A systematic scoping review","volume":"20","author":"M Ansu-Mensah","year":"2020","journal-title":"BMC Health Serv Res [Internet]."},{"issue":"2","key":"pone.0299249.ref018","doi-asserted-by":"crossref","first-page":"e0184830","DOI":"10.1371\/journal.pone.0184830","article-title":"Has the free maternal health policy eliminated out of pocket payments for maternal health services? Views of women, health providers and insurance managers in Northern Ghana","volume":"13","author":"PA Dalinjong","year":"2018","journal-title":"PLoS One [Internet]."},{"issue":"1","key":"pone.0299249.ref019","first-page":"1","article-title":"Out-of-pocket payments in the context of a free maternal health care policy in Burkina Faso: A national cross-sectional survey","volume":"9","author":"IB Meda","year":"2019","journal-title":"Health Econ Rev [Internet]."},{"issue":"1","key":"pone.0299249.ref020","first-page":"1","article-title":"Exploring inequalities in access to and use of maternal health services in South Africa","volume":"12","author":"SP Silal","year":"2012","journal-title":"BMC Health Serv Res [Internet]."},{"issue":"6","key":"pone.0299249.ref021","doi-asserted-by":"crossref","first-page":"701","DOI":"10.1016\/j.healthpol.2021.04.009","article-title":"Inequality in out of pocket fees, government funding and utilisation of maternal health services in Australia.","volume":"125","author":"EJ Callander","year":"2021","journal-title":"Health Policy (New York)."},{"issue":"2","key":"pone.0299249.ref022","doi-asserted-by":"crossref","first-page":"e000085","DOI":"10.1136\/bmjgh-2016-000085","article-title":"Wealth, education and urban\u2013rural inequality and maternal healthcare service usage in Malawi","volume":"1","author":"S Yaya","year":"2016","journal-title":"BMJ Glob Health [Internet]."},{"key":"pone.0299249.ref023","doi-asserted-by":"crossref","first-page":"49685","DOI":"10.1136\/bmjopen-2021-049685","article-title":"Open access Multisite, mixed methods study to validate 10 maternal health system and policy indicators in Argentina, Ghana and India: a research protocol","volume":"12","author":"R Jolivet","year":"2022","journal-title":"BMJ Open"},{"key":"pone.0299249.ref024","journal-title":"Recommendations for refining key maternal health policy and finance indicators to strengthen a framework for monitoring the Strategies toward Ending Preventable Maternal Mortality (EPMM) [Internet]"},{"issue":"4","key":"pone.0299249.ref025","doi-asserted-by":"crossref","first-page":"1467","DOI":"10.1111\/1475-6773.12444","article-title":"High Out-of-Pocket Medical Spending among the Poor and Elderly in Nine Developed Countries","volume":"51","author":"K. 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Analysis of the 2014 Ghana demographic and Health survey.","volume":"21","author":"EK Ameyaw","year":"2021","journal-title":"BMC Pregnancy Childbirth [Internet]."},{"issue":"1","key":"pone.0299249.ref036","doi-asserted-by":"crossref","DOI":"10.1186\/s12884-016-0875-2","article-title":"The obstetric care subsidy policy in Burkina Faso: What are the effects after five years of implementation? Findings of a complex evaluation","volume":"16","author":"R Ganaba","year":"2016","journal-title":"BMC Pregnancy Childbirth."},{"key":"pone.0299249.ref037","doi-asserted-by":"crossref","first-page":"33","DOI":"10.2147\/OAJC.S153443","article-title":"Does courtesy bias affect how clients report on objective and subjective measures of family planning service quality? A comparison between facility- and home-based interviews.","volume":"9","author":"W Hameed","year":"2017","journal-title":"Open Access J Contracept."}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0299249","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,3,13]],"date-time":"2024-03-13T17:39:15Z","timestamp":1710351555000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0299249"}},"subtitle":[],"editor":[{"given":"George","family":"Vousden","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2024,3,13]]},"references-count":37,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2024,3,13]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0299249","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,3,13]]}}}