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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. Rationale for the review Methodology for the review - PowerPoint PPT Presentation
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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++ + + ++ + +