Health insurance is relatively new in all four countries. Ghana has the most extensive formal health insurance enrolment (47%) compared with 36.6% in Rwanda, 25% in Kenya and 14.5% in Tanzania. Rwanda has the most elaborate Community-based Mutual Health Insurance program. Tanzania covers some transportation costs for maternity, and Rwanda has experimented with inclusion of emergency transportation services. Although exemptions and fee waivers for common maternal care (i.e., ante- and postnatal care, and simple delivery) exist in all the schemes, inconsistencies and ambiguities and poor knowledge of the system of waivers and exemptions frequently result in payment of official and unofficial fees. Catastrophic maternal payments are common. In Ghana, sometimes mothers or their new born children are detained for nonpayment. In Kenya and Ghana, many households are compelled to sell assets to pay for care. Kenya’s hidden fees inflate user costs but Rwanda has clear and unambiguous co-payments. Ghana has the best maternal care indicators of the four countries. It has the lowest median months pregnant at first visit to an antenatal care facility; 84.3% of pregnant mothers satisfy the WHO recommended 4-5 antenatal care visits per pregnancy compared to 13.3% in Rwanda or 52.3% in Kenya. In Ghana, 47% of births are attended by a trained professional compared to 46% in Tanzania, 42% in Kenya and 38.6% in Rwanda. Ghana also has the highest rate of postnatal care while Rwanda has the lowest.