Governments in many low- and middle-income countries have increasingly turned to the private sector to address the gap in skilled birth attendance in rural areas. They draw on limited, but emerging evidence that the poor also seek private healthcare services. A question not addressed in this policy and strategy is: Can poor women pay the fees required for private-sector maternity care providers to financially sustain their practices? This article examined the financial viability of private-sector midwifery practices established to provide skilled birth services to Afghan refugee women in Baluchistan, Pakistan. An international non-governmental organization established 45 midwifery practices as part of a poverty alleviation project aimed at providing market-based solutions for female poverty. A retrospective micro-cost analysis was conducted on a sample of 11 practices. In-depth interviews were conducted with 33 stakeholders to explore the midwives' experiences of operating private practices, and the facilitators and barriers they experienced. The single midwife-practices saw a mean of 8.7 ANC patients (range 1-19), attended 2.9 births (range 0-10) and provided care to 1.6 postnatal patients (range 0-7). The average net income of the 11 practices in May 2014 was US$81, but the median was just US$12. To contextualize these incomes, the midwives earned, on average, 25% of Pakistan's minimum monthly living wage. The financial analysis showed only 3 out of 11 sampled practices could be considered financially viable. The qualitative data revealed that even in practices with reasonable client volumes, the patients' inability to pay was the critical factor in the midwife practices' low net incomes. The research provides empirical evidence of a potential pitfall of private funding models in resource-poor settings where providers rely on impoverished clients to pay user-fees. Such financial models essentially shift the government's responsibility to provide safe childbirth services onto providers who can least afford to offer such care.
Keywords: Pakistan; Private sector health care; financial analysis; maternity care; poverty; skilled birth attendants.
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