Bruno Meessen In this blog, Bruno Meessen (ITM, Antwerp and facilitator of the PBF CoP) shows how Results Based Financing could be a lever for African governments in the battle for family planning … and even more so, when other influential actors in society are hostile.
On sticks, carrots and sermons
Whether you are a general, the leader of a gang, the boss of a big company, or a parent desperately trying to maintain authority, you have three main instruments to steer the behavior of your fellows and subordinates: sticks
The metaphor of a ‘stick’ describes the variety of devices you have at your disposal to deter and, if necessary, punish behavior not in line with your objectives. This is the fine a policeman gives you if he sees you driving without a seatbelt, for example, or the shot in the knee (at best) for the villain who betrays his boss, the non-renewal of a contract for a supplier due to poor service,…
The ‘carrot’ is of course used as a metaphor for a reward. A medal for a brave soldier, for example, a diploma for a diligent student, the price paid to a baker for his delicious bread and of course, pay for performance, which I’m sure I don’t have to explain on this blog.
By ‘sermons’, we mean all strategies and tools of education and persuasion. Economists will tell you that these aim to change the preferences of economic agents. More prosaically, the aim is a situation where your fellows, convinced by the strength of your discourse, spontaneously adopt behavior aligned with your goals. This usually happens after you have offered convincing arguments, but if you also have a certain moral authority (like the mother has towards her child, the teacher versus his students, or the priest towards the parishioners), you have an additional advantage.
These tools all have their strengths and weaknesses, and need to be assessed in their particular situation. PBF experts, if they believe in the power of ‘carrots’, also know carrots can’t change all behaviors. ‘Sermons’ will be particularly useful when it’s impossible to verify behavior or when behavior that needs to be encouraged is also beneficial for the one adopting the behavior (example: usage of a condom). Note also that the times are changing: our societies cherish more and more individual freedom and responsibility. ‘Sticks’ are thus less and less tolerated and certain forms used in the past are now even prohibited by law. Let's appreciate the opportunity offered by Results-Based Financing (RBF)
These are thus the three tools available to governments to influence the behavior of their citizens. In this respect, it is clear that RBF, by its very nature, is a significant enrichment of the toolbox of African governments. But my wish is that they use this instrument in an even more strategic way, more in particular when they face other leaders promoting views contrary to their own vision of development.
Let’s give an example. Imagine a country which faces a serious demographic problem, to the extent that the high birth rate puts more and more pressure on the economy and more fundamentally, undermines the opportunities which could be available to citizens in the future. Imagine that the government has identified family planning by informed parents as a human right, on the one hand, and as a necessity to boost the development of the country, on the other hand. Imagine then that a prominent religious leader promotes a totally different vision … with a sermon, of course.
What should the government do in this case? Should it opt for the ‘stick’ (eg summon the hierarchy of the religious leader, with the threat of a sanction), or for a confrontation of ‘sermon’ (by the president) versus sermon (of the bishop, for example) on the issue at stake? If I were president of this (imaginary) country, I would think twice. If the bishop (for example) has dared to challenge you over this issue, it’s no doubt because he knows that the balance of power is not exactly in favor of you for the moment. At certain times in the life of a politician, a public confrontation on a particular topic can obviously harm his (or her) goals: the church he/she faces can be very powerful; moreover, given the church’s commitment to social sectors (schools, health centers, …) it will remain a partner for the government to work with. So it’s important to choose your battles – but this, we don’t have to tell politicians. Results-Based Financing: a powerful lever for change
Faced with this situation, are you powerless then? Before RBF, this was probably the case. However, I think RBF now offers new and ‘smart’ opportunities for government action. The first option, if it hasn’t been implemented yet, is to add family planning to the grid of PBF of health centers (i.e. to reward the health centre for each new woman adopting a modern contraceptive method). If family planning indicators are already present, the government could increase reimbursement rates (as it has been done in Burundi late 2012). This may be powerful, but not enough, especially if many health facilities are affiliated to the church challenging your national policy! I supect that the real breakthrough will come from involving the communities
. First, the government could, like in Makamba
(Burundi), contract community associations to refer women interested in family planning. But the government could go even further: it could decide to introduce a voucher system which would encourage women to adopt a modern contraception method. To distribute these vouchers in the community, we would mobilize of course the many female community health workers (with a small compensation for every woman they refer to the health center!). Being wives, mothers, sisters, friends and neighbors, I’m sure they would find the right words to convince their peers.
By mobilizing the women in communities in Africa and tapping a peer-to-peer educational strategy, it seems to be me RBF can mobilize hundreds of thousands of very persuasive agents
who can even beat seasoned preachers, if need be!
Let us forward this message to political leaders of Africa.Looking for more resources on RBF & family planning?
Reproductive Health Vouchers: from promise to practice, T. Boler & L. Harris, 2010, Marie Stopes International.
Voucher schemes for sexual and reproductive health services: a Marie Stopes International (MSI) perspective, factsheet.
Can incentives strengthen access to quality family planning services? Lessons from Burundi, Kenya and Liberia, L. Morgan, 2012, Health Systems 20/20, USAID.
Bouchra Assarag (National School of Public Health, Rabat) interviews Fabienne Richard (Institute of Tropical Medicine, Antwerp) about a recent publication on fee exemption for maternal care.
In your article, you discuss the various policies of fee exemption for maternal care in 11 countries in Africa. What was your objective and what has been your strategy to collect information?
The article is based on a study we conducted in preparation for the meeting of the CoP financial access in Bamako in November 2011. The workshop focused on the exemption policy for maternal care. We did this preparatory work to give participants an overview of what is currently being done in various Anglophone and Francophone countries in terms of maternal health exemptions. The comparison of 11 countries in terms of coverage of care packages and financial mechanisms chosen by the countries has been a good starting point for the exchanges.
To gather the information, we first developed a grid (with one part focusing on the package of care covered by the policy and another part on the financing modalities) which we have tested in Burkina Faso. Once the grid was validated, we sent it to the 11 countries, more in particular to the person or department in charge of monitoring the exemption policy. In general, technicians of the Ministry of Health and/or the Ministry of Finance have completed the form. We sometimes used on-site researchers to validate or complete the form when some data were incomplete. We then tried to find the similarities and differences between countries. What are the main findings of your analysis?
First, there is a wide variation in terms of covered services or types of cost covered by maternal health exemption policies. The minimum strategy, everywhere, was to make caesarian sections free, but the variations around this minimum are obviously important too: complications or not, normal births or not, post-abortion care or not, etc. The justification for a particular covered package in terms of health benefits or in terms of reduction of catastrophic expenditure is rarely made explicit in the formulation of a policy. Governments have not always allowed technicians the opportunity to make estimates and analyze the cost-effectiveness of a particular option. Certain policies have been decided very quickly by the president in the context of an electoral campaign, which did not exactly facilitate their implementation.
Second, fee exemptions for maternal care are not the only targeted initiative to reduce financial barriers. Recent years have seen the blossoming of a number of initiatives to reduce the financial burden of certain population groups (pregnant women, children, elderly, poor, …) or patients with a certain disease (HIV, malaria, tuberculosis, …). This becomes very complex for caregivers to navigate, to know which paper to fill out in order to claim such free care. These initiatives, most of the time managed separately by different departments at the central level, are a burden to the hospital or district (specific monitoring tools, different reimbursement mechanisms, …). Some people will be doubly covered, like a child under five years old suffering from malaria, as many countries have programs for children under five as well as for malaria. But a 15 year old boy who is the victim of a traffic accident with his motorcycle in town will be far less lucky, as he doesn’t fit any category… but he needs surgery and this costs a lot… As for a forty year old woman who suffers from obstetric fistula following a difficult delivery, idem. The reply to her will be that it’s not on the list of emergency obstetric interventions.
In sum, even if fee exemption policies started from good intentions – to improve maternal health and reduce the financial burden on families, they may not achieve their goals because they have often been formulated too narrowly (selecting only caesarian section in the covered package) or because their implementation has not been adequately prepared. A few years ago, you coordinated a collective
work entitled “Reducing financial barriers to obstetric care in low-resource countries”. Which link do you see between this book and this new article? What is your personal analysis of the free maternal care policies, in terms of implementation, impact for women or children, or repercussions for health systems?
I would say not much has changed in terms of implementation of policies since writing our book: in almost all countries, there has been a gap between what was theoretically foreseen and what has actually been understood and implemented. Several factors can explain this: a fuzzy formulation of the policy (each has his own interpretation of the content of the package), a lack of monitoring of the policy and control measures to set things right if one has moved too far from the policy as it had been conceived, a lack of accompanying measures in terms of human and material resources.
My own analysis, based on observations in the field (as I’ve lived the life of frontline health staff in several African countries) is that human resources are vital for health systems and an essential element for fee exemption policies to succeed. The state can inject millions in an exemption policy and announce that everything is free, but if in hospitals the nurses or other staff continue to accept informal payments, this will completely demolish the effect of the policy. Before launching such policies, we must think carefully on how to engage frontline staff so they can be policy stakeholders.
For the future, regarding the variety of targeted exemption policies I mentioned earlier, I really think we should join forces to achieve universal coverage. Many African groups have set up task-forces for health insurance, for example – which is positive – but sometimes with international partners without involving colleagues who manage targeted exemption policies. There is therefore still a lot of coordination work to do at the national level to synchronize efforts made by all. I’ve understood that the communities of practice received Muskoka funding from France to work on this, which is great news, as there’s plenty of work to do. To conclude, will we see you at the conference of the Community of Practice in Ouagadougou in November?
Of course! I heard the program is of high quality. With many other researchers, including from Benin, Burkina Faso, Mali and Morocco, we will present the results of the FemHealth project
, which focused on exemption policies in maternal health. I hope this conference will provide answers to the questions that remained unanswered after the Bamako workshop … as well as our review of 11 countries.
From November 25-28, 2013, a workshop on maternal health fee exemption policies is being organised in Ouagadougou (Burkina Faso). Its objective is to draw conclusions on such policies through research results and the experiences of key actors.
For more than a decade now, a number of African countries have been implementing national fee exemption policies targeting certain services (HIV, malaria, deliveries, Caesarean sections, etc…) or specific population categories (children under 5, pregnant women, the elderly, etc…). The objective of most of these policies is to increase chances of reaching the MDGs and also to reduce financial barriers to accessing health care.
If there is one major shortcoming, however, it is that most of these policies were hurriedly implemented
, began on a national scale without a pilot phase, and worse, without having designed or put in place any evaluation mechanisms to measure their effects.Knowledge on fee exemption schemes: much production, but too little sharing and utilisation
Such highly political processes and hasty implementation present clear methodological challenges to those who wish to evaluate fee exemption schemes. And yet, many different research programs have undertaken studies on the subject and their results are now starting to become available. A number of NGOs have documented their fee exemption interventions. Managers of fee exemption schemes and front-line implementers also have important tacit knowledge that should be shared.
One common characteristic of the period in which these policies were implemented (2000-2010), is that there existed no platform in place for exchange and knowledge management among implementing countries. No doubt this at least partially explains why technical and scientific knowledge already available at the time was rarely used to improve fee exemption policies, leading to a cycle of repeating the same avoidable mistakes.
This situation did, however, lead people to realize the importance of creating such a platform for knowledge and experience sharing, and as such, the Financial Access to Health Services Community of practice (FAHS CoP) was launched. A more scientific workshop
So it is with great pleasure – and we think a fair amount of legitimacy, that the FAHS CoP announces the upcoming workshop in Ouagadougou dedicated to the evaluation of maternal health services fee exemptions in Africa.
Many of you will remember the one held in Bamako in November 2011
. With this upcoming, and most likely last CoP workshop on the topic, we feel confident we can close this chapter of knowledge production.The Ouagadougou workshop will be more scientific than Bamako was: it will allow us to highlight and share the knowledge created through studies carried out on maternal health fee exemptions by different research consortiums, including those linked to the FEMHealth project
, the University of Montreal
and the University of Heidelberg.
The workshop aims to bring together countries implementing maternal health fee exemptions with research teams who have been investigating these policies in Africa. The goal of this workshop will not be to judge the choices countries have made regarding maternal health fee exemptions, but rather to help them to make them more effective and efficient so as to improve the health of their populations.
In order to facilitate a maximum of exchange, a call for abstracts
covering 10 themes has been issued not only for researchers, but also for managers and implementers of such schemes. We would like to invite you to share your experience on the topic through this blog, and also by submitting an abstract for the Ouagadougou workshop
. On behalf of the Institute for Health Sciences Research (Ouagadougou), we look forward to welcoming you to Burkina Faso.(Translation: Allison Kelley)
Yamba KafandoDu 25 au 28 novembre 2013, se tiendra à Ouagadougou (Burkina Faso) un atelier sur les politiques d’exemption pour les services de santé maternelle. Son objectif principal est de faire le bilan de ces politiques à partir des résultats de différentes recherches et des expériences des acteurs-clés.
Depuis plus d’une décennie, de nombreux pays africains mettent en œuvre des politiques nationales d’exemption visant certains services (VIH, paludisme, accouchements, césarienne, etc…) ou certaines catégories spécifiques de la population (enfants de moins de cinq ans, femmes enceintes, personnes âgées, etc…). L’atteinte des OMD mais aussi le souci de réduire les barrières financières à l’accès aux soins des populations sont les objectifs poursuivis par la mise en place de ces politiques nationales.
On peut toutefois avoir un regret : la plupart de ces politiques d’exemption ont été trop rapidement mises en œuvre
, directement à l’échelle nationale, sans phase pilote et surtout sans planification d’un volet d’évaluation qui puisse permettre de mesurer leurs effets.Des connaissances produites, mais trop peu partagées et utilisées
De tels processus politiques hâtifs et généralisés d’emblée posent des défis méthodologiques à ceux qui veulent les évaluer. Malgré cela, divers programmes de recherche ont été entrepris ; leurs résultats commencent à être disponibles. Plusieurs organisations non gouvernementales (ONG) ont par ailleurs documenté leurs interventions. Enfin, les gestionnaires de ces politiques ainsi que les acteurs opérationnels détiennent aussi des savoirs tacites qu’il convient de mobiliser.
Un fait caractérisant la période pendant laquelle ces politiques de subvention ont été lancées (2000-2010), est qu’aucun mécanisme de partage des connaissances entre pays n’était en place. Cela a plus que probablement contribué au fait que les connaissances scientifiques et opérationnelles déjà disponibles à l’époque aient été peu utilisées pour l’amélioration de ces politiques, conduisant à la reproduction d’erreurs évitables.
Cela a suscité une prise de conscience qu’il fallait créer une plateforme de partage et a, de fil en aiguille, conduit à la mise en place de la Communauté de Pratique Accès Financier aux Services de Santé. Un atelier avec une orientation plus scientifique
C’est avec fierté que la Communauté de Pratique AFSS vous annonce la tenue prochaine d’un atelier à Ouagadougou consacré à l’évaluation des politiques de gratuité en santé maternelle. Certains d’entre vous se souviendront certainement de celui qui avait été organisé à Bamako en Novembre 2011
. Avec ce second et probablement dernier atelier sur cette thématique, nous pensons pouvoir boucler cet important programme de connaissances. En effet, l’atelier de Ouagadougou aura une nature plus scientifique : il nous permettra de prendre connaissances de différentes études menées sur ces politiques ces trois dernières années, notamment celles qui ont été conduites par différents consortia scientifiques gravitant autour du projet FEMHealth
, de l’Université de Montréal
et de l’Université de Heidelberg.
Concrètement, l'événement ambitionne de regrouper les experts mettant en œuvre des politiques d'exemption pour les services de santé maternelle ainsi que les équipes scientifiques qui se sont penchées sur ces expériences en Afrique. Le but de la conférence ne sera pas de juger les choix faits par les pays en matière de politiques d’exemption en santé maternelle, mais plutôt d'aider à les rendre plus efficaces et efficientes afin d'améliorer la santé des populations.
En vue de favoriser le partage d’un plus grand nombre d’expériences sur ces questions, un appel à communications
couvrant 10 thématiques a été lancé à l’endroit des chercheurs, des intervenants mais aussi des gestionnaires et des acteurs opérationnels.
Nous vous invitons donc à partager votre expérience en la matière sur ce blog mais aussi à proposer une communication pour la conférence de Ouagadougou. Au nom de l’Institut de Recherches en Sciences de la Santé, nous nous réjouissons déjà de vous accueillir au Burkina Faso.
The next interview of our series on community participation and the Bamako Initiative is with Dr. Agostino Paganini. Agostino Paganini has an extensive experience of primary health care and emergency health care in Africa, an area in which he has been active for over forty years. He was the manager of the Bamako Initiative Support Unit at the UNICEF HQ. The unit worked closely with African countries that had shown interest in the principles of the Bamako Initiative. In the first part of the interview we publish today, he shares his analysis of the set-up of the Bamako Initiative. Next week, we will discover his analysis of the evolution of the Bamako Initiative principles over time. Jean-Benoît Falisse: If I am correct, you took part to the Bamako conference. It was the 38th African Regional Meeting of WHO but UNICEF also became involved. What were you doing at that time? Where was the Bamako Initiative coming from? Agostino Paganini:
At that point of time, I was working on a joint UNICEF-WHO nutrition support programme. I was based in New York and technically working for WHO. I was not there in Bamako but my experience of the event is still vivid. I remember quite well the organisational implications and all the fall-outs of this initiative of Mr. Grant. Of course, everything in this conversation could be biased, it is my own experience that I have revisited and understood over the years. At that time, Dr. Halfdan Mahler
was the Director General of WHO and Mr. Jim Grant
was the Executive Director of UNICEF. Both were extremely charismatic and powerful leaders and they were two major figures in the public health and health development debate. Mahler had a focus on primary health care issues with a global vision and sensitivity to political implications. Grant was much more pragmatic, he believed in that sort of 'cold war vision' where there were little chances for big progresses and therefore he believed in incremental steps, bringing up health in the political arena. After the Harare declaration [on strengthening the district health
systems based on Primary health
care], Grant came up with Bamako. Not necessarily, as perceived by some, as a declaration antagonistic to Harare's but maybe as a more incremental, less 'visionary', declaration. Of course, for him it was also a way to call for Africa because he wanted more resources for health organisation and child survival in Africa and he saw the declaration as a way to have them. Basically, the relation between the Bamako and Harare declarations could be seen in the context of an intellectual debate between these two giants of developmental issues. In the context of this intellectual debate, who was pushing for the Bamako Initiative? What were the main points of consensus and divergence between the countries and/or organisations?
Alongside with the African Ministers, UNICEF promoted and lobbied for this kind of declaration – for which WHO was not especially keen. Actually, even some parts of UNICEF were not happy about this. At the policy level, what was obviously the most difficult to accept was the issue of user fees and cost-sharing. UNICEF and Mr. Grant, on the basis of what was happening in Benin and many African countries, realised that the real payer in health was not the government any more, it was not even the donor any more, it was the household. The majority of expenditures were paid out-of-pocket. The issue was therefore 'co-financing'. Yet, some people identified this idea of having people co-financing their health services with the World Bank vision on user fees and the debate became very ideological. In the proposition for the Bamako Initiative, it was suggested that people would pay something out-of-pocket. If donors were helping making the service better in terms of infrastructure, drugs availability, training and supervision of staff and monitoring mechanisms, it would be wrong that people do not contribute to the cost of delivering services (although paying less than the actual cost). However, that money would stay with people who paid, at the health centre level, and it would be controlled by the community. That was the hypothesis. The reaction from the other side was to call this opening the door to privatisation and a way to have people pay for health when health is a basic human right which cannot be sold. Part of the Bamako Initiative is about community participation. In the interview with Susan Rifkin, she says what sparkled her interest in community participation was the experience of barefoot doctors in China. Was there anything similar in Africa? Something that convinced people in Bamako?
In the unit I was managing in New York, everybody was absolutely convinced that the biggest political change that Bamako initiative was bringing was not the money but the effort to empower the community in controlling their health centres and staff. We had the impression that the health staff had basically privatised the health system. The health system was not functioning any more. It was an unregulated private sector in which you would have to pay for everything without any control on the quality or the use of the money. For us, the Bamako Initiative was a way to strengthen the capacity of people to be part of and take part in the management of the health centre. It was not about the technical management of the health centre but about the ‘governance’ aspect of it. Was it successful? Well, in certain places like in Mali in the beginning it was quite good. Yet, I had the impression that after a while the Bamako Initiative was interpreted/considered by some of the Ministries of Health and staffs as an excuse to charge whatever they wanted with no control by the community on the money. Community-wise, what was in place at the time of the Bamako Initiative declaration?
In some countries, there were health committees but these health committees never controlled any resource. In these countries, we could start from these committees. However, in other countries such as Guinea after Sékou Touré, there was nothing. The health system had been destroyed and with the Ministry of Health of Guinea, managing committees were set up. It was the beginning of giving substance to community participation through the co-financing and co-management of the health centres. That was the language we wanted to use; not ‘cost recovery’ but ‘community co-management and co-financing’. It was implemented in different countries and under different labels. This is a labour intensive process that requires a lot of assistance at the community-level. The Bamako Initiative could be described as having three pillars: (1) community participation, (2) self-financing mechanisms and (3) regular supply of drugs. You already touched the first two issues, could you say a word about the regular supply of drugs?
The experience on the ground was that health centres were not used and their utilisation was incredibly low for two reasons: (1) one was linked with the infrastructure and the behaviour of the staff which were perceived as rotten and so the centres were going down and the other (2) was that there were no drugs. Medicine is perceived by the users as the key element in the therapeutic process, and this is basically true wherever you are. People were spending their money on the market, buying drugs in the unregulated market or anywhere else. It was obvious that medicine had to be available in the health centre. The health centre had to become the place not only for preventive care but also for curative services. Do not forget that the main preoccupation of UNICEF at that time was not curative care; it was mainly immunisation and child survival (which are mostly linked to preventive care). However, having people coming to the health centre because of the availability of medicine for their curative needs was an important key for preventive purposes.
I take an example: child survival and malaria were two of Africa’s very obvious problems which were not very well addressed. There were vertical programmes with antibiotics and antimalarial drugs but they were not sufficient. Having a functional health centre was seen by us as a way to move towards a much more comprehensive vision of primary health care. It was a gradual process through which health staffs were trained and health centres improved thanks to investments from donors and the government. The running costs that were not covered by the government were co-financed by the community. The key was to have a committee which would oversee the management of the money so that there was public accountability. Community participation was seen as a way to obtain accountability from the medical and managerial staff. Monitoring was also a pillar in the system because it would allow the managing committee and the staff to have a view on coverage and immunisation, number of visits, number of women who were delivering babies, etc. This way they could set objectives, discuss between the members of the committee and the health staff, find bottlenecks in the system, and eventually improve the durability, access and correct utilisation of health care.
From April 16-20, 2012, two Communities of Practice - "Performance Based Financing" and "Financial Access" - gathered at a workshop in Bujumbura to discuss "Improving financial access to health care: the potential contributions of performance based financing." The workshop was largely built around the experience of Burundi - the first country to have merged its selective “free healthcare” policy (children under 5 and pregnant women)and performance-based financing (PBF) policy. Seeing and hearing about this original experience firsthand allowed participants to identify ways to improve the fee exemption policies existing in the health sector in their own countries. Dr. Hamidou Oum Ramatou Ganda (HR), Director of the Organization of Care at the Ministry of Public Health of Niger answered Bruno Meessen (BM)’s questions. BM: in 2006, Niger set up an ambitious free Caesarean-section and healthcare for under five children. During the workshop, you shared with us the difficulties this policy has encountered. You spoke of a national conference held in March around the fee exemption policy in Niger (the final declaration entitled "Free health care in Niger is seriously ill, let’s save it" is available in French here). What was the motivation for this conference?
RH: We realized that the level of government debt, which is the third-party payer for the fee exemption system, towards health facilities, is piling up. It is unable to make reimbursements
; moreover there is no verification system in place. It was necessary to identify the bottlenecks
and try to find solutions to sustain the health care fee exemption strategy.
The first bottleneck identified was financing. Beyond the public budget line, which does not cover all costs, there is no other source of funding. One goal of the workshop was to advocate for finding other financial means to continue the fee exemption policy. We also pointed out management problems, whether over-billing or the method used to reimburse health facilities. Finally, we also discussed the problem of drug supply and consumables, for it is only after having been reimbursed that health facilities can order and buy more drugs. Because of the lack of reimbursement
, health facilities are running out of cash, and this creates either stock-outs or debts to private suppliers. As a result, the performance of health facilities is compromised in terms of effective provision of their package of activities. One of the particularities of the national conference was to be multisectoral.
Indeed, we tried to bring together all stakeholders: beneficiaries, senior officials in the health sector, but also representatives of local governments, civil society, NGOs, technical and financial partners, and all other ministries directly or indirectly involved in the “free healthcare” policy: these include the ministries of education, labor ... We were 178 participants gathered together to highlight problems and outline solutions. What progress has been made since the conference?
We are studying the most urgent issue, i.e. the reimbursement of the arrears that the state owes to health facilities. Moreover, all the recommendations from the conference are being converted into a roadmap with timelines and responsibility levels identified. It is followed closely by a committee that was established by a ministerial decree. This committee’s mandate is to ensure that all recommendations are implemented. This committee is headed by the deputy secretary general of the Ministry of Public Health, who must also report to the Prime Minister at least once a month. There political commitment is quite strong. After this workshop in Bujumbura, would you have any additional recommendations besides those already made at the National Conference?
I think we can already try to apply the system of verification and validation of invoices to our free healthcare, as it exists in PBF. This can be done without waiting for the national scale-up of PBF implementation. As for PBF, we are still in the study phase. We can apply PBF’s verification system to improve the free healthcare strategy, paying only the actual costs incurred and adjusting the system. To me, this is the main lesson.
Traduction: Emmanuel Ngabire
In this blog, Divine Ikenwilo comments on a recent declaration of commitment by the Pan African Parliament. He shares his doubts about the impact of such declarations.
The year 2011 will, perhaps, be remembered as the year in which the fight against maternal and child deaths and ill-health received parliamentary support for the first time. Following the 3rd Pan African Speakers’ Conference in Johannesburg (October 17-18, 2011), African Speakers of Parliaments and Presidents of Senate 'unanimously adopted a landmark resolution on a Declaration of Commitment
to prioritize parliamentary support for increased policy and budget action on Maternal, Newborn and Child Health in African countries'. This commitment, hailed as the first of its kind by African Speakers of Parliament, is expected, among other things, to improve political support to prioritising policy and financing of care for mothers and their children.
It is perhaps right in assuming that this commitment was necessary in the face of continuing evidence of the position of the continent (vis-à-vis other continents) in achieving targets for maternal and child health set out under the Millennium Development Goals 4 and 5. For example, despite improvements over the last eleven years, under-five mortality and maternal death rates in sub-Saharan Africa are the highest in the world and still above the MDG target rates. Any efforts to bring these (and many other health related problems) down will go a long way in not only achieving the MDG targets, but also improving life and the general well-being of the people of sub-Saharan Africa (SSA).
In a continent where a majority of health care financing is from private sources, with too often catastrophic consequences especially for the poor and vulnerable, an increase in the proportion of government spending on health could, all things being equal, be expected to improve universal access to vital care such as those for maternal and child health. The speakers’ commitment also comes with specific targets to increase government allocation of health spending to various levels (and in most cases, targeting the 15% mark agreed at the Abuja Declaration in 2001). The targets for specific countries also mean that policy makers, researchers and other observers can monitor progress towards the objectives.
In making a case for continued government intervention in the production of goods and services, economist John Kenneth Galbraith, had the following to say; ‘in the evolution of economic enterprise, the things which could be produced and sold for a price were taken over by private producers. Those that were not, but which were in the end no less urgent for that reason, remained with the state’. Although the private sector is still able to play an active role in the delivery of health care, the role of government becomes more sacrosanct as a result of the need to encourage universal coverage of health care services to cater for the vulnerable and thus improve equity.
Despite potential increases in government spending following the speakers’ declaration, there is evidence that increasing government spending on health does not necessarily favour the poor (Castro-Leal et al., 2000
). Similarly, despite the abolition of user fees, financial protection remains elusive, as out-of-pocket spending remains high among the poor (Nabyonga-Orem et al. 2011
). The inability to attain stated objectives is largely blamed on improper consultation and unexpected timing of such political declarations, unmatched by adequate preparations for reform (Meessen et al. 2011
). It is now over 10 years since African Heads of Government committed to increasing government health spending to 15% of their respective national public budget. Critics would say that most countries have hardly met that 15% target while parliamentarians are committing to more promises.
In light of the foregoing, the impact of the speakers’ declaration on actual improvements in maternal and child health in the continent therefore remains doubtful. For now, it is just a statement of intent, and there is nothing binding in that commitment. There is hardly any continuity in some governments and parliaments in the continent, which mean that new governments and parliaments usually change everything; every declaration, every policy, every promise. It may therefore be useful to entrench the current speakers’ declaration (and any such declarations) in law (if possible) so that it remains binding on present and future governments.
In sum, the question that remains on my mind is whether this declaration is driven by political expediency or whether indeed, there is hope for us in the continent. It is now up to the parliamentarians to work with their respective governments and relevant ministries (for example, of health, finance and economic planning, who actually plan health care services) towards making a difference, not only in maternal and child health, but in the health of the entire people of our dear continent.