How to remove user fees

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

The Policy Process of Removing user fees in health services in low-income countries: a framework for a multi country review

How to remove user fees

David Hercot, Bruno Meessen, Valery Ridde & Lucy Gilson

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Outline Rationale for the review Methodology for the review The Five Elements of The Framework

Discussion

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Rationale for the Review

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Rationale for the Review

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Methodology

• Sept 2008

Data collection

• Nov 2008

Cross country analysis

• Dec 2008

Report

• Feb 2009

Methodology for the review

FIVE ELEMENTS OF THE POLICY PROCESS

Unintended positive impact

Intended impact

Unintended negative impact

content

actors

process context

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Good Practice Hypothesis

a well-documented and assessed practice that provide evidence of success/impact and which are valuable for replication, scaling up and further study

Methodology for the Review

FIVE ELEMENTS OF THE POLICY PROCESS

Unintended positive impact

Intended impact

Unintended negative impact

content

actors

process context

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Situation analysis

Priority Setting

Option Appraisal

Programming

Implementation

M&E

Process: The Rational Planning cycle

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

1. Thorough Situation Analysis

Process: Preliminary situation analysis

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

2. Clear Policy Objectives 3. Vision, ownership and leadership

Process: Priority Setting

   BFaso Burund

i LiberiaUgandaGhana

Senegal

1. Preliminary situation analysis Yes +/- No Yes No +/-

2. Clarity of the policy objectives Yes +/- +/- Yes Yes Yes

3. Vision, ownership and leadership Yes +/- Yes Yes +/- +/-

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

4. Use of International and National Scientific evidence

5. Considering different policy options 6. Thorough assessment of the option 7. Early identification of accompanying

measures 8. Preferences of key stakeholders met

Involve Stakeholders when designing

Process: Option Appraisal

   BFaso Burund

i LiberiaUgandaGhana

Senegal

6. Thorough assessment of the option Yes No No No No No

7. Early identification of accompanying measures No No No Yes No No

Replace lost revenues: – increased salaries, – PHC funds, – special additional funds for

drugs. Revision of incurred costs

Did Senegal consider the expected increase in utilisation?

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

9. Testing the reform 10. Planning implementations steps 11. Commitment on budgetary burden 12. Clear and robust rules for

transferring resources

Process: Programming

  B Faso Burundi

Liberia

Uganda

Ghana

Senegal

9. Sequencing of the reform No No + No + +

In both countries, No assessment of first stage before phase 2

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Situation analysis

Priority Setting

Option Appraisal

Programming

Implementation

M&E

Process: The Rational Planning cycle

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

13. Technical leadership 14. Coordination unit 15. Capacity building 16. Communication strategies 17. Actors abide by the new rules

Process: Implementation

  B Faso Burundi

Liberia

Uganda

Ghana

Senegal

14. Empowered coordination unit + + ++ ++ No +

An existing task force took the responsibility to follow up implementation issues

The coordination unit did not produce procedure manual nor policy paper in 6 months

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

18. Monitoring and Evaluation Indicators:

utilization rate, the disbursement rate, drugs stock out,

Longer term evaluation patient satisfaction, financial protection,

quality of care,

Process: Monitoring and Evaluation

FIVE ELEMENTS OF THE POLICY PROCESS

Unintended positive impact

Intended impact

Unintended negative impact

content

actors

process context

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

GlobalNation

alHealth

• MDG, Abuja• Donor policies• Macroeconomi

c• Governance• WHO Building

blocks

Context

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

  Post-conflict countries: Burundi and Liberia

Stable countries: Burkina Faso, Ghana, Senegal and

UgandaAid 

Emergency actors phasing out

Development actors well established

Political agenda

Wide range of political, social & health reforms ongoing (social reconstruction). 

A highly visible policy measure can help for re-election.

Health system

Disorganized & weakly regulated. To be rebuilt.

In place, yet performance can be quite low in some countries.

Information system

Non-existent. No studies. Weak Health Information System (HIS). Weak monitoring & evaluation.

Stronger HIS. Tradition of research better established.

Context

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

• Users• Urban/

Rural• Men/

women

• institutions• NGO Unions

press

• Ministry Officials & Staff

• Central & Local Government

Elected Officials

Appointed

Officials

Individuals

Members of

Interest groups

Actors

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Government – users

Free Care

Government – Facilities

Access to resource and their use

Content : Analyzing contracts

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Before

• Bamako Initiative

• Drug purchased by health facility and sold

Formulation

• Free care for all assisted deliveries

• Drugs provided to the facilities for free

Implementation

• Only urban women in public sector

• Drug stock out -> Private providers

Content over time

FIVE ELEMENTS OF THE POLICY PROCESS

Unintended positive impact

Intended impact

Unintended negative impact

content

actors

process context

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Impact

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Discussion

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

http://www.itm.eu/unicef

Thank you

   Burkina Faso Burundi Liberia Uganda Ghana Senegal

1. Preliminary situation analysis Yes +/- No Yes No +/-

1. &3 International and National Scientific evidence +/- No No No Yes  

4. Clarity of the policy objectives Yes +/- +/- Yes Yes Yes

4. Considering different policy options Yes No Yes Yes No No

4. Thorough assessment of the option Yes No No No No No

4. Early identification of accompanying measures No No No Yes No No

4. Vision, ownership and leadership Yes +/- Yes Yes +/- +/-

4. Involving in the formulation stage stakeholders crucial for the implementation +/- No No No No No

4. The content of the reform meets preferences of stakeholders Yes Yes Yes +/- Yes Yes

   BFaso Burund

i LiberiaUgandaGhana

Senegal

4. International and National Scientific evidence

+/- No No No Yes  

5. Considering different policy options Yes No Yes Yes No No

6. Thorough assessment of the option Yes No No No No No

7. Early identification of accompanying measures No No No Yes No No

8. The content of the reform meets preferences of stakeholders

Yes Yes Yes +/- Yes Yes

Involving in the formulation stage stakeholders crucial for the implementation

+/- No No No No No

 Burkina Faso Burundi Liberia Uganda Ghana Senegal

1. Sequencing of the reform No No + No + +1. Planning process + No + + No +1. Communication strategies – Stakeholders (not

users)++ No No + + +

1. Communication strategies – Users + + + ++ + +1. Medium term commitment on budgetary burden

++ + ++ ++ No No

1. Channelling of resources Same New Adapt Same New New1. Leadership by the government ++ + ++ +++ + +1. Capacity building

+ No No No No No

1. Empowered coordination unit+ + ++ ++ No +

1. M&E of the reform+ + + +++ No No

1. Enforcing the reform++ + + ++ + +