FACILITATOR’SNOTESON:

“Kenya:PolicyDevelopmentandImplementationofUserFees”

1. Objectives

Thisexerciseisintendedtoallowconsiderationbothofsomekeytechnicalissuesto considerinuserfeedesignfeatures,andofthefactorsthatneedtobeconsidered whenthinkingaboutimplementinguserfeesystems.

2. Description

TheexerciseusedinformationdrawnfromtheKenyanexperienceofuserfee implementationinthelate1980s-1990s.It is,however,presentedthrougha hypotheticaldialoguebetweentwoseniorofficials.

Smallgroupsareaskedtousethediscussionsbetweenthesetwoindividualsasthe basisforconsideringthreequestions.Thesmallgroupdiscussionsshouldbefedinto a plenarysession,wrapped-upwithasummaryofkeyissuesbythefacilitator.

3. Preparationandlinkages

Theexercisecanbeusedbeforeorafterabroader introductiontouserfeesystems. Suchanintroduction shouldcovertheobjectivesofuserfeesystems,keyissuesin userfeedesign,thekeyfactorslikelytoinfluencetheirimpacts,andthebroader rangeoffactorsinfluencingtheirsuccessfulimplementation. Ifusedbeforesucha session,participants wouldrequiresomefamiliaritywithhealthcarefinancingissues andconcerns ingeneral. Ifusedaftersuchasession, theexercise wouldallow participantstoapplyknowledgealreadygained.Theexercisecanusefullyformpart ofaseriesofsessionsonhealthcarefinancingtopics.

Iftheissuesaroundthedesignofuserfeesystemareignored,theexercisecould alsobeusedwithinaseriesofsessionsconsideringhowissuesof thepolicyprocess affectimplementation. Inthiscase,itshouldbeprecededbypriordiscussionofthe natureofthepolicyprocessandtheprocessfactorsinfluencingimplementation.

4. Timingandlogistics

Overalltheexerciseshouldtakearound2hours.

Initiallyparticipants shouldreadthroughthedialogueindividually, notingpointsfor discussioninthesmallgroups(15-20minutes).

Theninsmallgroupsof5-6people,thethreequestionshighlighted intheexercise shouldbediscussed.Allowroughly40-60minutes forthesediscussions–andmake surethegroupscoverallquestions!

Finally,allow40minutesorsofortheplenarydiscussionandwrap-up.Oneapproach totheplenarydiscussionistodiscusseachquestionseparately. Getonegroupto giveaninitial5minuteinputontheirresponses tothequestion, andthenaskother groupstocomment andaddinmoreideas.Thenmoveontothesecondandthird questions, getting a different group to lead the discussion in each case. This

approachavoidsduplication butallowsallgroupstohaveinput.Allowafinal10 minutesorsotosummariseandwrapupthediscussions. Onlyhighlightkeypoints, andusethistimetomaketheconnections betweentheexerciseandearlier sessions/sessionstocome.

5. Pointsfordiscussion

Someof theissuesto considerin facilitatingthefinalplenaryandpreparingthewrap- uparelistedbelow.

1)Userfeedesignproblems:

•mainconcerns:whatistheinfluenceofuserfeelevelsonaccess/utilisationby differentpopulationgroups(equity)andutilisation levels/patternsofhealthfacility use (efficiency)?how much revenue can be generatedwithout undermining utilization?

•note income distribution and poverty levels in the country and utilisation reductionsafterfeesimplemented

•mechanismstoprotectpoorinthe1989userfeeschedulelookreasonablebut didpoorreallybenefit?howeffectivelyweretheyimplemented?

•revenue retention at facility may undermine mechanisms to protect poor

(exemptionsleadtolessrevenue,andsolessbenefitforfacility)

•no by-passchargefor those who go direct to hospitals– mightencourage unnecessaryutilisationofhospitals?asmightreferralfee!

•paymentofall-inclusiveconsultationfeewhennodrugsavailableundermined patientwillingnesstopay

2)Userfeeimplementationproblems:

•implementationeventuallydoneveryrapidlywithlittletimeforpreparation

•limitedcapacityatnationalleveltoprepareforimplementation

•limitedcapacityatdistrictleveltoensureimplementation–DHMBsnotfunctional

•MinistryofFinancereservationsaboutMOHaccountingprocedures

•politicalinterferenceinimplementationoncenegativeconsequencesclear

•weakimplementationof parallelpoliciesthatsupportfeeimplementation,i.e.drug availabilityproblems

•administrativeproceduresforcollectingrevenuefrom NHIFpatientscumbersome andsodifficulttoimplement

•bankingandaccountingproceduresweaklyimplemented

•fewexemptions/waiversofferedinpractice byheathworkers because undermine revenuegeneration,andrevenuenotusedtoimprovePHCservicestobenefit thepoor

3)Generalissuestothinkaboutinimplementationprocessesinclude:

•preparation e.g. building capacity at national and district level, developing procedures thatarereasonable easytoimplement, takingstepstoensuredrug availabilityandqualityimprovements

•communicationwithimplementorssoknowwhatsupposedtodoandwhy;offset concernstheymayhave

•communicationwithpublicsoknowwhatischangingandwhy,whattheycan expectandaboutwhattheycancomplain

•establishingproceduresthatallowlearningfromimplementationtostrengthen nextstepse.g.phasingimplementation overtimeorgeographicalareas, monitoringexperienceandfeeding-backintoimplementation

•developingpoliticalsupportbeforechangeisimplemented

4)ThenextstepsactuallyadoptedbytheKenyangovernmentwere:

•StrengthencapacityoftheHealthFinancingSecretariat

•Phaseimplementationofnewuserfeesoverseveralyears–startingwith provincialhospitalsandworkingdowntohealthcentres

•Developnewadministrativesystemsandtrainstaffinnecessaryskills–againto bephased

•Prepareacomprehensivehealthfinancingstrategyforthecountry

•Allowfeestobespentonnon-personnelexpendituretoencouragequality improvements

•Promotepublicinformationcampaigntodispelpoorimageofuserfees

•Chargefeesonthebasisoftreatment(noofdrugsreceived)

•Performfullevaluationafterafurthertwoyears.

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