This study was carried out in three hospitals, which according to the experience of the researchers operate in the same manner as other public hospitals in Morocco. However, we do not know whether they are close to the average or whether there is a divergence; it is thus not possible to generalize our results to all the Moroccan public hospitals. A representative sample from the regions would have allowed us to confirm the effect of the fee exemption policy. Also, the interviews were carried out over a very short period and do not allow us to confirm that the levels and ratios of the different expenses are similar over the year.
The Moroccan fee exemption policy has certainly shown some efficacy since it made the medical and surgical acts free for every woman in the public hospitals. We do not know if it is an advantage for the poor who benefited in the past from the poverty card to cover all the expenses charged by the hospital. As it is not easy to get a poverty card, the universal fee exemption certainly has had the effect of simplifying the procedure and allowing the less poor to save 283$. It also showed its limitations since it does not seem to apply to the Fez UH, although the MOH and the UHs agreed to apply a fee exemption when women are referred from a regional hospital. This may need further investigation.
The extra costs for the purchase of medicines which are not included in the caesarean « kit « are not statistically different at the UH compared to the SEGMA hospitals. The "free" caesarean section, however, amounts to an average of US$169 (95% CI: 153-185) at SEGMA hospitals and US$291 at the UH. This extra cost may jeopardize the fee exemption policy. Can this cost be reduced? The cost of purchase of pharmaceutical products could be lower. The prescriptions on leaving the hospital show that currently the prescribed drugs are, or can be, available in the hospital pharmacies. The total amount paid for prescriptions on leaving the hospital is inflated by the costs of prescriptions for anticoagulants. These are systematically prescribed in SEGMA hospitals. They are administered during the hospital stay (2 or 4 injections) and prescribed on leaving (6 injections). The issue of whether these are really necessary remains an ongoing debate. At the UH, prescription of anticoagulants is not systematic: only 50% of women were prescribed this treatment. The cost of the prescribed drugs was around US$85 ± 45 in the SEGMA hospitals, nearly half the direct expenses of the households that sometimes are unable to pay for the complete treatment. This is also the case elsewhere, where drug expenditures represent a significant portion of expenses, ranging from 18 to 55% for most countries and even reaching 70% in Bangladesh and India [11
]. Sometimes, patients could not take prescribed medication because they could not get it due to stock shortages [12
In the direct costs of a caesarean section, the total transport cost, which on average amounts to US$52 ± 31 for the SEGMA hospitals, represents nearly one third of the expenses for the family. The big part of this cost, however, comes from the journeys made by the husband who needs to visit his wife every day; this part can hardly be covered by the policy. The transport by ambulance had to be paid for in a third of the cases (4 out of 12) as no ambulance from the Ministry of Health was available, although the ministerial decision included transport with an ambulance from home in the rural areas and between the peripheral maternity and the hospital for women who needed to be referred. In other countries this is equally an important cost and ranges from 2.23 US$ in Benin to 59.94 US$ in Bangladesh for a complicated delivery [13
In areas of difficult geographical access, it becomes particularly important, averaging between US$15 and 41, as in Nepal where transport accounts for over 50% of the cost of a normal delivery, and 25% of the cost of complicated childbirth [14
]. In Cambodia, the cost of transportation is the biggest barrier, even more than the costs of care in health facilities [15
]. The cost of transportation accounted for 71% of total costs in Tanzania [16
The cost of extra food and the opportunity costs were not significant in this study. Internationally, the loss of income of the companions was significantly higher in the case of a complicated delivery: US$4.13 (in Bangladesh) to US$78.5 (in Tanzania). The opportunity cost in Ghana was also 5% of total costs [13
The cost of tips and informal payments, which averaged US$20 ± 12 in SEGMA hospitals (for the 46% of people who said they made such payments) does not represent a significant expense. The ethical weight of this cost is higher than the financial weight, since it represents only 6% of direct costs of a caesarean section in SEGMA hospitals and 1% in the UH. Flexible visiting hours, the time allowed for these visits, the opportunity for the father or the family to take the baby instead of the hospitalized mother keeping it, the quality of meals served and the professional attitude are all factors that fuel the practice of informal payments to obtain rights and privileges. This calculated average is minimal compared to other countries where informal fees can be substantial. In India, they are 5 times more important than administrative costs and account for 80% of total direct spending by households [17
]. In Kenya, they represent 59% [18
]. The practice of informal payments is common and applies to all categories of medical, paramedical and administrative staff. It was estimated at about US$20 per hospitalization in Madagascar [19
The inclusion of the UH in the fee exemption system needs to be resolved urgently. In fact, UH users paid an average administrative cost of US$138(95% CI: 98-178), which almost doubles the cost of a caesarean section. Most women, however, were referred to the UH without necessarily having had a choice.
As a result of the fee exemption policy, the reduction in direct costs for women delivered by caesarean section in SEGMA hospitals amounts currently to US$114 on average (compared with the US$283 paid on average before). This is a reduction of average direct costs of 40%. Extreme amounts paid range from US$26 to US$ 376, this cost taking into account the intervention and the hospital stay which may vary between 4 days and 1 month according to the complications. This 40% average reduction is higher than the one recorded in Ghana, where a 28% decrease was reported in the average cost of caesarean deliveries and after the policy of fee exemption was introduced [20
]. In another study, the reduction in direct costs for women amounted to between 195 US$ and 153 US$ for caesarean sections [21
Our results can also be interpreted more positively when we look at the percentage of the fee exemption in the SEGMA hospitals in comparison to the average direct cost of a caesarean section. The reduction even exceeds 80% of the cost when the patient receives free medication.
This is a major benefit in terms of reduction of family expenditure. However, our study was not able to show whether the fee exemption benefited the poorest families.