Fee exemption policies for maternal health care: some issues from the field of health
economics
Technical workshop on the benefits package for fee exemption policies for maternal health services – Bamako 17-19 November 2011
Bruno Meessen & Matthieu Antony
Objectives
• “Free” care has several merits, but it also has a cost.
• Identify some key issues relating to health economics and provide food for thought on fee exemption policies.
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Methodology
• Questionnaire developed by the FEM Health team with validation by the workshop organizing committee (2 parts: content and funding)
• Pre-test in Burkina Faso• Sent to all countries that participated at the
workshop by email to a key informant at central level
• Follow-up by telephone and email• Comparative analysis of 11 sheets
How to allocate resources?
The determinants of budgetary weight of exemption policies
• The targeted population and fertility rate as a crucial factor• The range of services included in the policy• The costs covered by the policy
Exemption policy coverage
Different criteria, different winnings
Criteria: support by citizens (benefits, justice)
Criteria: protection against catastrophic expense
Key question: which is the optimal cube in terms of winnings for populations (possibly with different weights), givens limited resources, systemic issues and dynamics?
Criteria
: cost-effectiveness
Exemption policy
coverage
Year 2010 Morocco Ghana Burundi Burkina-Faso Kenya Nigeria Sierra Leone Senegal Mali Niger Benin
Amount allocated to maternal health care funding (in PPP$) - - 10 410 789 - - - - - 6 657 455
(2009)4 847 560
(2009) 8 689 281
Amount allocated to maternal health care and newborn funding (in PPP$) 62 876 604 - - 14 410 789 8 897 766 - - - - - -
Amount allocated to maternal health care and children under 5 years funding (in PPP$) - - 27 355 978 - -
59 471 658(nov 2008-june 2010)
11 673 382 - - 17 223 343(2009) -
Antenatal care
Delivery
Episiotomy
Complication during pregnancy DC DC DC
Complication during labour
Caesarean section
Other surgeries Hyster. Hyster. Hyst+Ect.P Hyst+Ect.P
Postnatal care
Postnatal Complications
Postnatal family planning
Simple post-abortion care
Complicated post-abortion care
Newborn care
DC = Directs obstetric ComplicationsHyster = hysterectomyEct.P = Ectopic Pregnancy
Covered by another exemption or subsidy policy
Example : estimation of unit cost of C-Section
Benin Burkina Faso Morocco Senegal Kenya Niger Mali0
50
100
150
200
250
300
350
400
450
Estim
ated
uni
t co
st o
f Cae
sare
an s
ectio
n (in
PPP
$)
Available fiscal space, political commitment
Sources : authors' calculation
0 500 1000 1500 2000 2500 3000 3500 4000 4500 50000
0.5
1
1.5
2
2.5
3
3.5
Burkina Faso
Morocco
Kenya
Burundi
Niger (2009)
Sierra Leone
Nigeria (Nov 2008- Juin 2010)
BeninBurundi
Mali (2009)
Niger (2009)
Exemption policy cost/Capita and GNI/Capita (in PPP$) in 2010
Maternal health care funding Maternal and children under 5 years care funding Maternal and newborn care funding
GNI/Capita
Exem
ption
pol
icy
cost
/Cap
ita
Resource mobilization
• State budget only
– Benin– Burkina Faso– Ghana– Morocco– Nigeria– Senegal
• State budget and Foreign aid
– Burundi– Kenya– Niger– Sierra Leone
Share of foreign aid in the exemption policy funding
Burundi Kenya Niger Burkina Faso0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
World BankEuropean Com.Belgian Coop.
NGOs
KfW
AFD
UNFPAWHO
UNICEF
State Foreign aid
Features of foreign aid
• The aid is mainly but not only monetary…– Niger : aid is monetary and non-monetary (drugs, contraceptives,
transport in the case of referrals)
• Multiplicity of donors – Sierra Leone : DfiD, World Bank, AfDB, UNFPA
• Donor commitment?– Burundi and Kenya: funding commitment from donors until 2014– Niger and Sierra Leone : Donor commitment does not specify
duration– Burkina Faso : no commitment
=> Sustainability of policy funding an issue?
Forecast versus actual disbursements in 2010
* Maternal health care only
Burundi* Kenya Benin Burkina Faso0
4000000
8000000
12000000
16000000
Forecast expenditureAmount disbursed
How to compensate providers for delivering “free” services?
The incentives issue
The issue
• User fees are a mechanism for rationing scarce government resources (and development partners) but are also part of a set of incentives for providers
• By removing it, (1) set up another system of incentives; (2) exposure to another form of rationing (stock-outs, burn-out…)
Incentives / Effects• For users:
– Access– Distortion that may shift demand (i.e. Benin).
• For providers:– Effort in terms of quantity of services produced– Effort in terms of quality of services provided to users – Effort in terms of the management of resources within health facilities or the
health system– Effort in terms of reporting
• For donors:– Effort in terms of resource mobilization– Effort in terms of disbursement
Funding arrangements
BurundiGhanaBurkina FasoKenyaNigerBeninSierra LeoneNigeriaMaliMorocco*Senegal**Annual prepayment (in regional hospitals only in Senegal)
Impact on drugs supply: « push » or « pull »? Parallel system?
Supply of kits
Care reimbursement
Care reimbursement and supply of kits
Care reimbursement and capitation payment
Different approaches to fixed fee
• Unique fixed fee regardless of level of care (Benin, Mali, Morocco, Nigeria).
• Fixed fee depending on level of care (Niger, Ghana*). * In Ghana's case this depends on the ownership of the facility as well as the level.
• Kenya : fixed fee depends on ownership of health facility (public, faith-based / NGO, private for profit).
• Burundi : one fixed fee but «equity bonus system».
• Burkina Faso : reimbursement of health facilities based on the actual cost of care.
Key question: Does the fixed fee cover marginal cost? Does it take into account staff motivation? What effects, distortions?
Performance-Based Financing: interesting option?
• Combination between selective free and Performance-Based Financing (Burundi).
• Principles:– A purchasing agency offsets each patient accepted according to a standard
fee that builds in an amount for staff incentive.– Compensation can be a criteria in terms of quality of care.– Facility has enough autonomy to decide on the use of resources (i.e.
Burkina Faso). – A verification agency checks the physical reality of the benefits reported.
• Difficulty: assessing the quality of maternal health care (Caesarean section)
Frequency of reimbursements/prepayments
MoroccoSenegalSierra LeoneKenya*BurundiGhanaNigerBeninMali (kits)Burkina Faso* Normally on a monthly basis
Mali (reimbursements)
Nigeria
Are there any delays in the reimbursement of health facilities that threaten their financial health (debt accumulation)?
AnnuallyBiannuallyQuarterlyMonthlyAt the discretion of the facility
Conclusion
• “Free” care through fee exemptions has a significant cost to governments. Crucial issue!
• We are looking for the optimal system. It is important to explain the decision criteria. Some options raise questions.
• There is no single funding strategy for exemption policies.
• Don’t neglect the accompanying measures and the key role of incentives => Importance of formulation phase (design!) and implementation.
• Need for a good information system to correct the adverse effects.