Handling client financial insolvency in maternity services: An occurrence, experience and policy gap qualitative analysis among healthcare stakeholders in North-Central Nigeria.

Objective: To assess the occurrence of client financial insolvency, experiences of key healthcare stakeholders, and policy gaps on handling the situation during maternity services.

Methods: A qualitative study was conducted in North-Central Nigeria. Participants were key healthcare stakeholders including healthcare workers from private, primary, secondary, and tertiary facilities, healthcare administrators/facility-heads, program managers and policy makers at local and state government levels through In-depth and Key Informant interviews. Identified themes were occurrence, experiences of stakeholders, and prevention of client financial insolvency. Data were analyzed with the Nvivo statistical package.

Results: Participants confirmed the occurrence of client financial insolvency. Clients' inability to pay hospital bills was due to being indigent, awaiting support from relations, or clients who were uncommitted to the payment. Health facilities lack guiding policy documents; potential cases are referred from private to public or from primary to secondary/tertiary facilities. Methods of handling financial insolvency included healthcare worker-related (staff scavenging for needed consumables, fund-raising among facility staff), facility-related (revolving fund, medical social welfare, welfare committee, discharge with re-payment plan, fee-waiver), community-related (ward development committee, religious organizations/philanthropists) interventions, or hospital detention of insolvent clients. Although clients' bills did not increase during detention, many clients did not honor post-discharge re-payment agreements. Participants suggested a client-friendly billing system, early initiation of birth preparedness, partner involvement, and a rapid scale-up of health insurance for pregnant women to curb financial insolvency.

Conclusion: Tackling client financial insolvency requires policy documents, support to private facilities, effective debt-recovery mechanisms, and scale up of health insurance for pregnant women.