IMPROVING FINANCIAL ACCESS
TO HEALTH SERVICES
in west and central africa
Report of the Technical Workshop To Share Experiences
in the Development and Implementation of Policies to improve financial access to health services for the poor
Dakar, Senegal - November 2-4, 2010
Harmonization for Health in Africa (HHA)
Disclaimer
The technical opinions expressed during the workshop and in this report do not necessarily reflect the views of HHA agencies or other participating agencies.
Contents
Disclaimer ………………………………………………………………………… P. 2
Acronyms ………………………………………………………...... …………………. P. 4
Executive Summary …………………………………………………………………. P. 5
Introduction …………………………………………………………………………. P. 6
1. Policy Development to Improve Financial Access to Health Services P. 7
Across the continent… …………………………………………………………. P. 8
Some operational lessons …………………………………………………………. P. 10
Recommendations …………………………………………………………. P. 11
2. Policy Implementation and Evaluation to Improve Financial Access to Health Services ……………………………………………………...... ……...... P. 12
Across the continent… …………………………………………………………. P. 13
Some operational lessons …………………………………………………………. P. 16
Recommendations …………………………………………………………. P. 17
3. Sustaining the Momentum: The Community of Practice on Financial Access to Health Care ……...... …………………………………………………………….. P. 18
Annexes ...... P. 21
Annex I: Workshop Agenda ………………………………………………………….. P. 22
Annex II: List of participants …………………………………………………...... P. 24
Annex III: Exemption of User Fees: Recent experiences in African countries ...... P. 28
Annex IV: Extract of the Workshop Technical Note …………....……………………. P. 29
Annex V: HHA Partners and Workshop Organising Committee ………………….. P. 33
Annex VI: Background Documents …………………………………………………. P. 34
Annex VII: Recommendations listed by stakeholder (decision-makers,
partners, experts) ...... P. 36
Annex VIII: HHA Communities of Practice ……...... …………………………….. P. 37
Annex IX: The Performance-Based Financing CoP on the Internet ………...... P. 38
Acronyms
AfDB African Development Bank
AfHEA African Health Economics and Policy Association
CNRST Centre national pour la recherche scientifique et technique/
National Scientific and Technical Research Centre
CoP Community of practice
ECHO Humanitarian aid department of the European Commission
EmONC Emergency Obstetrical and Neonatal Care
FAHC Financial Access to Health Care
HHA Harmonization for Health in Africa
HIPC Heavily Indebted Poor Countries
IRSS Institut de recherche en sciences de la santé/
Health Sciences Research Institute
ITM Institute of Tropical Medicine (Antwerp)
JICA Japan International Cooperation Agency
MDG Millennium Development Goals
MLI Ministerial Leadership Initiative for Global Health
NHIS National Health Insurance Scheme
NGO Non Governmental Organisation
PBF Performance Based Financing
SCO Civil Society Organisation
TFP Technical and Financial Partners
UNAIDS Joint United Nations Programme on HIV/ AIDS
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
VAT Value Added Tax
WAHO West African Health Organisation
WB World Bank
WCARO West and Central Africa Regional Office (UNICEF)
WHO/ IST World Health Organisation/ Inter-country Support Team
Executive Summary
Improving Financial Access to Health Services – HHA, Dakar, November 2010 Page 2
In recent years, African countries have witnessed increasing policy momentum for improving financial access to health care. In order to support their policy initiatives and respond to the need for sharing these experiences across countries, the “Harmonization for Health in Africa” (HHA) Partnership brought together 16 country delegations and representatives from research institutes and technical and financial partners (TFP) in Dakar, November 2-4, 2010.
Country experiences and working group discussions showed that policy initiatives to reduce financial barriers to care were often launched without any preliminary feasibility or costing studies. Vulnerable populations (pregnant women, children under 5 years of age) were targeted as a priority, but the packages of services covered by the initiatives were often limited and other costs (e.g. transportation) ignored.
Also, implementation often suffered from a lack of accompanying measures, which may have had negative effects on quality of care, staff motivation and the functioning of health services.
Nevertheless, these initiatives seemed to get general buy-in and were able to secure initial funding thanks to strong political will. Whether funding for such initiatives is managed efficiently or sustainable remains a major concern. In several countries, policy adjustments were made to correct these types of inadequacies.
In general, in spite of the lack of in-depth studies and impact evaluations, the equity dimension of such initiatives remained a challenge, with recurring shortcomings in the identification and care of the poorest.
Recommendations highlight the following elements:
Ø the need for consulting stakeholders during the whole process;
Ø the importance of a good technical design of policies, including accompanying measures;
Ø the need to institutionalize processes and financing;
Ø the need to further involve communities and civil society along the way, from the baseline situation analysis to the impact evaluation, through the verification of policy implementation and service quality, the management of funds to reimburse providers and the identification of indigents.
At the regional level, the main recommendation is to better share country experiences (development, implementation, results evaluation), so as to build capacities, inform decision-making and solve common issues.
This implies conducting more research before, during and after policy implementation (costing studies, benefit-incidence analysis, evaluations), and also further disseminating the results of this research and of current experiences.
In order to do this, a mechanism for sharing and documenting experience on an on-going basis should be put in place that links scientists and practitioners in the field of policies to improve financial access to health care.
The suggested mechanism to respond to this need is a Community of Practice (CoP) dedicated to the issue of financial access to health care, within HHA established CoPs. It will bring together available scientific knowledge with practitioners’ expertise.
Active participation in this CoP (to be launched in early 2011) by African technicians and decision-makers, as well as researchers, NGOs and other partners, will provide a continuous platform for sharing existing knowledge and generating new evidence, based on consensus around common needs.
Reflexions and discussions, focusing on practical issues around design and implementation, could help countries to solve challenges and make quicker progress towards effective, equitable and sustainable policies.
Improving Financial Access to Health Services – HHA, Dakar, November 2010 Page 2
Introduction
Improving Financial Access to Health Services – HHA, Dakar, November 2010 Page 2
In the last few years, there has been increasingly strong policy momentum to improve financial access to health care in African countries, with the recent implementation of around fifteen initiatives to abolish user fees[1], as well as some national initiatives to expand health insurance.
Today, taking position for or against “free”[2] health care does not seem relevant anymore. The challenge is to support evidence-based, comprehensive financing strategies and to provide technical assistance to governments that engage in such initiatives to improve policy development, implementation and integration with other strategies (e.g. national and/ or mutual health insurance, performance-based financing - PBF).
This is why, in 2008, UNICEF commissioned a multi-country review, implemented by Antwerp’s Institute of Tropical Medicine (ITM). The study aimed to describe African countries’ experience with user fees abolition and to identify lessons learned and “best practices”.
In the six countries[3] of the study, results showed there was strong political will behind user fee abolition. Financing for these initiatives was often made possible through the Heavily Indebted Poor Countries (HIPC) Initiative. However, it was clear that measures to abolish fees were sometimes put in place too hastily, without real involvement or dialogue with key stakeholders, and with few accompanying measures. Provider payment mechanisms and terms were not adequately developed and financing often insufficient, as was coordination, monitoring and evaluation mechanisms.
The review also recommended enhanced knowledge transfer between African countries.
After a wide stakeholder consultation, the Dakar Workshop was organized in order to meet this need[4]. The objectives were the following:
- To share experiences between African countries;
- To draft a common set of lessons learned and “best practices”;
- To make technical recommendations to political decision-makers and technical and financial partners;
- To foster, in each country, concertation mechanisms for harmonizing initiatives aimed at improving financial access of priority groups to health care;
- To launch a sustainable regional impetus for knowledge sharing on the issue at stake, putting practitioners at the heart of the network dynamics.
The workshop was an opportunity for HHA partners [5] to collaborate with other institutions also interested in enhancing knowledge, information and experience sharing between countries in the region, such as: The Ministerial Leadership Initiative For Global Health, the African Health Economics and Policy Association (AfHEA), the Institute of Tropical Medicine (ITM) in Antwerp and the Health Sciences Research Institute (IRSS/ CNRST) in Ouagadougou.
The workshop showcased the views of those who are dealing with the day-to-day implementation of free care initiatives. This type of field practitioner knowledge is extremely valuable, even though scientific evidence remains a critical counterpart[6]. The challenge is to combine both.
This report is based on country experiences, inputs from the working groups and comments from the participants.
It features highlights from the country presentations made during plenary sessions: Burkina Faso, Burundi, Ghana, Ethiopia, Mali, Nigeria and Sierra Leone.
The experiences of the countries presented during parallel sessions, although they are not detailed here, have also significantly contributed to the reflexion (Senegal, Benin, Liberia, Congo, Niger, Uganda, Zambia and Mauritania).
All presentations are available on www.hha-online.org.
Improving Financial Access to Health Services – HHA, Dakar, November 2010 Page 2
1. Policy Development
To Improve Financial Access To Health Services
Improving Financial Access to Health Services – HHA, Dakar, November 2010 Page 2
The elements presented here reflect the inputs from the participants, as expressed during country presentations, discussions (plenary and parallel sessions) and during the working groups that were organized on the eight following topics:
A. Interaction between policy-making and technical considerations, respective obligations and coordination mechanisms of policy makers and technicians
B. Targeting and coverage of the poorest (complementary measures)
C. Definition of target populations and package of services covered
D. Financing free care initiatives through the national budget and financial partners
E. Terms and mechanisms of payment of providers and the accompanying measures needed to ensure adequate drugs and human resources
F. Process of reform – Design, implementation, and institutionalisation
G. Stakeholder involvement and community participation in these initiatives
H. Monitoring and Evaluation.
In general, in the region, policies aiming to improve financial access to health services have often been launched following the publication of results of surveys or national health accounts that have drawn attention to the burden of out-of-pocket payments for households.
Regarding the package of services concerned by free care initiatives, two trends were observed: in some countries (mainly French-speaking African countries), “free” packages were limited to specific priority services, such as deliveries or Caesarean sections. In other countries, packages were more comprehensive and also included children under five years of age, or even the whole population.
Free care initiatives have often been launched without any feasibility study (costing, etc.) or with only rough analysis of the barriers to health care access. Most of the time, there has been no earmarked budgeting for such initiatives within an overall health financing strategy. To date, political will has been able to secure sufficient financing, but there are major management and sustainability concerns for the future of free care initiatives.
Despite mistakes in their design, there has been wide buy-in for these policies. However, the packages of services included are sometimes limited (e.g. in order to reduce maternal mortality, it will probably not be enough to abolish user fees for caesarean sections) and related, often important costs (such as transportation) have most often not been taken into account.
After a few years of implementation experience, policy revisions are often contemplated and should include serious consideration about how to be more efficient, equitable and sustainable.
Improving Financial Access to Health Services – HHA, Dakar, November 2010 Page 2
In countries where Health Insurance was created, the prevailing social and economic situation was worse than in African countries today;
leaders wished to improve their people’s health so that they could become more productive
– this is what should be considered now in our countries.
Pr Eusèbe Alihonou
Civil Society – Benin
Across the continent…
This section features highlights from the countries that presented their experience in plenary session. However, the country experiences that were presented during parallel sessions (Senegal, Benin, Liberia, Congo, Niger, Uganda, Zambia and Mauritania) have also significantly contributed to the findings. All PowerPoint presentations are available on http://www.hha-online.org/hso/financing/subpillar/Financial-Access-to-Health-Services/workshops/Dakarworkshop.
Improving Financial Access to Health Services – HHA, Dakar, November 2010 Page 2
§ Mali decided, in 2005, to abolish user fees for Caesarean sections in public health facilities. The package of services covered included pre-surgery tests, the procedure itself, a surgery kit (simple or complicated), hospitalization and post-surgery treatment. Linkages were in theory established with local solidarity funds for referral/ evacuation, in order to cover the cost of patient transportation from community health centres to referral centres.
An earmarked budget line item was created in the Finance Act. The funds allocated to this initiative have nearly quadrupled between 2005 and 2009 (from CFA 460 million to 1,800 million). Nonetheless, the strategy still needs to be adapted to better consider other delivery complications and transport costs, which continue to be an obstacle.
§ For the past four years, Burkina Faso has been implementing a subsidy for Emergency Obstetrical and Neonatal Care (EmONC) through third-party payer mechanism covering 60-80% of the cost, and a total fee exemption for indigents. All public health facilities were targeted, as well as private non-profit facilities under 3 conditions – standard fees,, standardisation of kits, and adequate quality of care. The cost calculated includes the transportation of the patient. Resources are advanced to facilities based on the number of expected cases.