Facilitation team

The new ambition of the CoPs is to increase opportunities for the CoP experts, through the launch of different collaborative projects. However, to make this transition possible we also need to reorganize our facilitation structure. In this blog, we present you the model towards which we are heading. If you have been with us for some time already in our CoP, there might very well be a new role for you!

The limits of the current model

In a recent blog, Bruno reviewed the five years of existence of the CoP Performance Based Financing (CoP PBF). He mentioned among other things how he has become sort of a bottle neck himself  as a key instigator and focal point of PBF CoP activities. In recent years, we have tested models with better equipped facilitation teams.   The Financial Access to Health Services CoP (CoP FAHS) went furthest in implementing this model. In the end, however, this approach did not lead to the expansion we expected to get.

In Rabat, we discussed this model of organization. For the PBF, FAHS and Health Services Delivery CoPs, the diagnosis was clear: so many of our beautiful projects have been put on hold due to our non-availability. We see the future in the model that was launched last year during the « Results Based Financing & Information Communication and Technology » workshop that was led by an autonomous central facilitation team.

The new model

To get rid of the bottle neck of facilitators, our new strategy will involve an organigram of facilitation that allows delegation of more responsibilities (the word « organigram » is not very appropriate as CoPs are not conventional organizations with a hierarchy and employees, but we could not find a better word for the time being). We are going to move away from our flat “rake” organigram towards a more decentralized organigram (see figure 1).

In practice, from now on, each activity of the CoP will be  conceived as a collaborative project. This project will be assigned to a “project manager”  (by the way, we find the term « project manager » not very original, and we will reward anybody among you who comes up with a better one with a PBF T-shirt – just offer your suggestions as comments to this blog). The main responsibility of the “project manager” will be to see the project through, from start to finish. These new project manager posts will be new opportunities for our more experienced and motivated experts. They can show their passion for knowledge management and their will to help the more junior experts to grow (in terms of knowledge, competences, …).

The selection of « project managers » will take into account the nature of the projects. In fact, as you’ll gradually discover as the collaborative projects will be shared online in the coming weeks and months, these projects will be of a different nature. Some will be relatively short, others will last for quite some time. Some will be small projects, others will be much heavier. Some projects will require both English and French, others not. Also, some will be more technical, others less. The title of “Project manager”  will thus be confined in terms of content and time. You should note that the expert who will have accepted this responsibility will have in advance agreed to precise terms of reference. He or she will also undergo an evaluation of his/her own performance (by his/her colleagues experts involved in the project).

Implementation

This model will be gradually implemented. The speed will depend, among other things, on the volume of collaborative projects that we will be able to launch. Obviously, it is possible that all will not work  smoothly from the beginning, but the most important is to start embracing this transition and take a decisive move forward, towards this new CoP development. We count on your support to succeed in this new model of facilitating CoPS.


Translation: Seleus Sibomana

Bruno Meessen

This blogpost introduces a multi-country research project looking at how at country level, Results Based Financing (RBF) schemes move from pilot to full integration into national health systems. The study is led by the Alliance for Health Systems and Policy Research and scientifically coordinated by the Institute of Tropical Medicine (ITM) and will be carried out by national research teams of eleven countries.




Worldwide, more than 30 low or middle-income countries are today developing, within their health sector, experience with so-called RBF strategy. While a few of them have already moved to a full-fledged national policy, most of them are still in pilot stages. This large international movement is facilitated and boosted by a number of forces and positive synergies: political will, aid agencies’ leadership and financial resources, enthusiasm of experts, commitment of major stakeholders, pro-active knowledge management…

The main goal of every RBF scheme is to improve the performance of the health system (measured in terms of quality of the health service delivered, coverage rate…). The ultimate goal of every - successful - pilot scheme is to be scaled up. From a knowledge management perspective, though, a pilot scheme which failed to improve some target indicators is actually still a success if the operational lessons which have been drawn from the experience allowed stakeholders to improve the national health system. This is an outcome which matters for an RBF strategy, as many have argued that its transformative power is one of its key attributes. A key metric of the ‘success’ of an RBF experience should therefore be its ability, through the core principles it promotes, to reinvigorate the national health system. One can foresee transformations/scale up on many different dimensions.

Launch of a multi-country research project

The possible journey “from scheme to system” will be the main focus of a  multi-country research project coordinated by the Alliance for Health Policy and Systems Research and the Health Economics Unit of the Institute of Tropical Medicine. This research program is sponsored by NORAD, the Norwegian Aid Agency.

The call for proposals launched by the Alliance sparked quite some interest: 34 research teams submitted a proposal. Eleven countries have been selected – you can discover which ones by clicking here.(1) Selected research teams have been informed. The next step will be a protocol development workshop to which the principal investigators of the eleven countries will be invited. Together, we will explore the commonalities across the 11 cases and assess whether we can adopt a common framework and select a limited number of common research questions.

After approval of the protocols by ethical committees, each national research team will document how the journey from scheme to policy is going in their respective country (although among the 11 countries, we have also interesting stories of pilot schemes which did not materialize into national policies). While our sampled countries are mostly from sub-Saharan Africa (the most dynamic continent, as far RBF is concerned), we are happy to have also three experiences from outside Africa. In Africa, we will cover a nice mix of settings: a few post-conflict countries, some Francophone and Anglophone countries, a mix of small and big countries.

Our communication strategy

While the PBF Community of Practice is not formally involved in this research at this stage, we will make sure throughout this project to keep you informed about the progress being made. We are indeed very aware that moving from scheme to system is a challenge that some of you are already facing today. So you may learn from what we discover… but we also value the knowledge you will share with us. This interaction with you will take different forms, but our online forum and this blog will be major tools (do not hesitate, for instance, to contact us if you want to write a blogpost on the situation in your country or just share some reflections). We will also seize opportunities offered by face-to-face encounters to discuss on this topic with you (as we did already in Buenos Aires and as we will do again at the Cape Town symposium, in a satellite session co-organized with the World Bank).

This promises to be an exciting journey. We hope that you will be with us all the way long.

 
Note:
(1) We are very aware that some readers of this blog post are disappointed by the non-selection of their proposal. Proposals went through  a systematic appraisal system set up by the Alliance. Feel free to contact Mrs Maryam Bigdeli at the Alliance to know the reasons why your proposal has not been selected.

Isabelle Lange
 
The  Harmonization for Health in Africa  Communities of Practice are today firmly installed in the global health landscape. The Financial Access to Health  Services  CoP (FAHS CoP) for instance gathers more than 700 experts committed to progress  towards universal health coverage through strategies such as user fee removal, health equity funds, health insurance…  In this blog, Isabelle Lange, medical anthropologist at the London School of Hygiene and Tropical Medicine and FEMHealth researcher reports findings of her qualitative research on the FAHS CoP itself. 

 “[The FAHS CoP online group] is effective for sharing information, for networking, and for the exchange of experiences…. It’s- it’s extraordinary…. First, through the community I discovered, I had the opportunity to exchange with a lot of people and now after the workshop, I think that they are friends… I will try to maintain these relationships despite…. Even if the relationship is there and exists you have to reinforce it and care for it.”
– Policy Maker, North Africa
 
More and more actors in the global health community are tapping into the growing range of resources to widen their networks and information bases. Communities of Practice (CoPs) fit into this trend, and as they become a more popular tool in today’s information management methods in global health, there is the sense that the utilization of the Internet and strong content can bridge individuals to create or strengthen a community.  A CoP then could provide resources for knowledge sharing and potentially also for informed health policy and systems change, breaking the traditional direction of north to south information flow and communication barriers across professional silos.  However, achieving this model can be a complex process dependant on many contextual variables; exploring the processes of a particular CoP can shed light on its contribution to health policy as a mechanism for knowledge exchange. This was one of my ‘assignments’ under the FEMHealth project.  
 
The CoP FAHS and the FEMHealth: three years of collaboration 
 
The FEMHealth project was a 3-year multi-disciplinary evaluation of maternal health user fee removal policies in Morocco, Mali, Burkina Faso and Benin. I carried out a semi-external view of FAHS CoP as a part of the health policy research. The health policy analysis aimed to understand the origin of the policies in these countries and why similar measures were taken around the same time period to reduce the financial burden of childbirth costs on women and their families.  There we explored whose voices were heard, which agendas were pushed and what evidence was influential in driving these strategies.  The FAHS CoP offered an arena to deepen that research by observing the current debates and actors, in addition to serving as its own study area on this mechanism as a
vehicle for knowledge sharing and transfer.  It also offered a channel to connect the FEMHealth researchers in with the wider community interested in their topic. As FEMHealth had supported the establishment of the CoP, it was also interested in understanding how well the CoP was meeting its goals of knowledge creation and exchange. In my capacity as anthropologist working on the health policy analysis research, I attended three FAHS CoP workshops (in Bamako 2011, Marrakech 2012 and Ouagadougou 2013) and alongside informal exchanges and observation of the content during those meetings, carried out in-depth interviews with the facilitators and about 25 participants – following up with a selection of them over the years to gain an idea of the value of the CoP within their professional and personal lives. 
 
CoP workshops

According to my informants, the CoP workshops cut across geographic, disciplinary and linguistic boundaries that frequently hamper knowledge exchange amongst different profiles of actors. The magic  formula for this was, according to participants: an appropriate participant body  – with engaged, knowledgeable actors there to learn and make a difference, not  just to collect per diems; dynamic, skilled facilitation; plenty of time for informal exchange (during coffee breaks or on field visits); quality simultaneous translation between French and English; pertinent technical content; and a format that allowed for questions, discussion, learning and problem-solving, not just presentations and “being spoken at.” 
 
A particular wish of participants was to have the beneficiary community voice present in the discussions, based on the feeling that they did not have space carved out to be legitimately heard in the usual pathways of decision-making. “I think that often we meet just amongst us, actors in the ministry of health, or those who implement the program, without taking many things into account because we can’t imagine the perspectives of the user or beneficiaries of the service”, stated a West African policy maker. “They have to be there to tell us ‘what you did like this, should have been done like this instead.”  This view was echoed in reference to other stakeholder groups, including health workers and researchers, underlining the absence of meaningful cross-silo exchanges in typical/existing professional structures. 

Importance of the online community

These workshops are an important part of the FAHS CoP identity – strengthening the membership and committing to action a core tenet of the knowledge-sharing mandate of CoPs. What was clear, however, was that the CoP workshops had another special component:  the online community that served as a base to these workshops.  This group offers a continuity and home to the technical content and face-to-face exchanges that similar conferences did not have. While many of the attendees at the workshops were not CoP members (at the time), the community thread ran through the conference and made its presence:
member participants were asked to summarize debates and presentations which were posted to the 700+ subscribers, who could then continue the discussion via email and feed back to the conference attendees with further thoughts and questions.  One workshop participant who is also a community member said, “I see these face-to-face meetings (as) very important. That's what feeds new community members and that feeds the online life to the next workshop. And so there are these two mechanisms – face-to-face - that are then a good trigger for online knowledge movement and communication and discussions.” 
    
In its own right, the online community served as a valuable link to work being done in health financing on a broader scale than many members were involved in their day-to-day professional lives.  Access to grey and academic literature, unpublished experiences, and especially the diverse opinions of fellow community
members on these pieces proved to be a reason why the online group was valued and, for some, ‘boosted confidence’ in their own capacity and was considered a unique contribution to the resources available in this field. 
  
Further reflections and future steps

The enactment of policy-relevant knowledge in more dynamic ways – through interactive meetings, continuous facilitation, editorials, and community building, among others – was seen to be a strong point of the community of practice model in providing both personal and professional benefits to members. But questions remain about strategies that can create a lasting impact in a world where many are over-worked and access to a surplus of material and resources can at times seem to be a burden rather than a benefit.  The CoP offers a reference point and an organizational component to information, people and networks, which, as one agency participant says, is “the key to the whole thing…. It’s knowledge dissemination, knowledge production, capacity building.” But, he continues, “a community of practice is not just there for the management, but to build something.” Over the past three years we have watched the FAHS CoP grow into a network of more than 700 individuals and as an organization have seen its presence at numerous conferences and affiliation with other professional bodies. Discussions around its ideal future structure emphasize its need to remain non-normative, independent and be member-driven,
not only member-responsive, in order to be able to contribute to shaping an environment that constructively and innovatively brings about positive policy advances through knowledge sharing. 
 
Read the accompanying policy brief for the facilitators’ perspectives on growing a CoP, and don’t hesitate to get in touch with any thoughts or ideas.  

Allison Kelley

In this blog post, Allison Kelley presents a descriptive research project being carried out by experts from two communities of practice – Financial access to health services and Performance-based financing - in twelve Francophone African countries.  One of the project’s innovations is its collaborative approach.

Universal health coverage (UHC) – is higher than ever on the agenda, both nationally and internationally. Presidents, key development partners, and even international NGOs are all pushing for UHC. What consensus! And yet – as is often the case – the devil is in the details – and in this case, in the many and ever expanding number of health financing schemes in African countries: user fees, budget allocation, funding inputs, community-based health financing schemes, fee exemptions for certain population groups, exemptions for the poorest, performance-based financing… Just to illustrate my point, one of our experts has already inventoried 29 different health financing schemes in Niger!

Such fragmentation in national health financing, without even mentioning the challenges of quality and human resources, can leave one feeling perplexed in the face of all the fervour around UHC.  How can the various pieces of the health financing puzzle be assembled to constitute a coherent picture at a national level? In many countries, there are a multitude of different actors involved in the planning and implementation of such health financing schemes (HFS), all with their own objectives. Many are unaware that they are in some way contributing to UHC in their country. They may also be lukewarm at the prospect of collaborating or being “rolled up” into some sort of larger scheme.

The diversity and confusion around various aspects related to the governance, objectives, intervention level, target groups, financing sources, available budgets, eligibility criteria, management and performance of these various HFS are such that no one today has the whole picture. And yet this picture would seem essential if a country truly wants to progress toward a more efficient and equitable national health financing system. It would also help to identify population groups that are less well covered, and those that may have double coverage (and those who stand to gain from such double coverage), inefficiencies, etc. I’d even suggest that having this full picture should be a prerequisite to defining and putting in place a national health financing strategy.

A multi-country study

Thanks to French Muskoka funding (with additional resources from Cordaid), experts from two CoPs – financial access to health services and performance based-financing – are carrying out a collaborative research project in 12 sub-Saharan Francophone African countries. Their goal is to map this tangle of HFS.  At the country level, we hope that this mapping exercise will create a clearer picture of the complexity of health financing schemes in-country. By comparing across the 12 countries we hope to be able to begin to trace some recurrent situations, or patterns, that we can interpret as favourable or unfavourable (using existing knowledge of health economics and political economy) toward expanding UHC.  

A collaborative process from A to Z

If this research is modest in terms of its scientific objectives (descriptive documentation only using existing secondary data and knowledge held by experts), it is more innovative from a methodological perspective: from its conception to its end, it is a collaborative process. 

Back in Spring 2012 (yes, it can take some time to turn an idea into a reality…), we organised a “virtual brainstorming” using the on-line discussion groups of two CoPs. We asked members to suggest priority research topics for a proposal to be submitted for French Muskoka funding (UNICEF WCARO). We then put the suggested topics to an electronic vote by members. The outcome was uncontested: the top priority topic was to better understand how to link up the ever-growing number of HFS at the national level in a coherent move toward UHC.

Since so many countries were interested in the topic, we opted for a more open research model that would capture a maximum number of experiences (rather than focus in on 1-2 countries): a sort of overview of what exists, not unlike the inventory carried out to prepare for the FAHS CoP’s first workshop in Bamako. We launched a call for individual experts to carry out the research at the country level. Because the Muskoka funding covered francophone countries (and only some of those at that), we ended up with candidates for 10 countries: Benin, Burkina Faso, Guinea, Ivory Coast, Mali, Niger, Central African Republic, Democratic Republic of the Congo, Senegal, Chad, and Togo. Our open model then led us to include two “non-Muskoka” countries, Burundi and Cameroon, thanks to Cordaid funding.

After signing the contract in Spring 2013, we were able to thus put the research team in place. A study guide was drawn up and shared with this team, and then improved through their comments and suggestions. A product of real joint collaboration!

What’s next

The research is finally underway. Researchers on the team are in continuous discussion on challenges, tips, and strategies for obtaining the financial data they need…

The results from this first phase of research – a mapping of HFS in 12 countries and a synthesis of the situation across these countries – will be presented at the March AfHEA conference in Nairobi shared more broadly by mid 2014.  This picture of almost a quarter of the countries in Africa should suggest some more general lessons and perhaps even some recommendations.

In early 2014, we will begin preparing the second phase of the research (to take place in 2014-15). Our intention is to develop a more in-depth questionnaire that we will test in at least one country. Phase 2 will thus take a “deep dive” in a number of countries (providing sufficient funding is available). We will attempt to document efficiency and equity losses due to overlapping and duplicative HFS and to identify areas for improvement. We expect that this second phase will produce concrete recommendations for each country studied in-depth.

This type of research project is definitely uncharted territory for the CoPs. Its the first time we have solicited member involvement for this sort of documentation. What we find especially interesting is getting involved in an area of research that is relatively less popular – multi-country studies and cross-country analysis. Between individual studies on health financing in a particular country and the tables WHO produces annually on international health spending, we think there is room!  And CoPs may just have a role to play, given their members span almost every country on the African continent. Still, our ability to succeed at such endeavours will depend on factors like our ability to coordinate amongst ourselves, and to help each other out where necessary. We certainly plan to document this original, collaborative research model along the way.

So stay tuned for preliminary results in early 2014. Here’s hoping that we can contribute to making more of the existing multiple and diverse HFS to expand UHC.

By the Facilitation teams of the HHA Financing CoPS * 

In early September, CoP facilitators gathered at the Institute of Tropical Medicine in Antwerp to reflect on the journey of HHA CoPs so far and to brainstorm on future development.** In this blog, the facilitators of the 3 ‘Financing CoPs’ revisit the role the communities of practice can play in promoting the UHC agenda. They also need your contributions, by the way…

Universal health coverage (UHC), whose aim is to ensure that all people obtain the health services they need without suffering financial hardship when paying for them, has recently risen to the top of the international health agenda. OK, so UHC may well be old wine in a new bottle, but if it helps to mobilize the troops, why not?

At this moment, the international community is still engaged in high-level negotiations on the exact make-up of post-MDG priorities. Judging by the actions,  reports and rhetoric at the latest General Assembly of the United Nations, it seems quite likely that UHC will be chosen as one of these priorities in 2015. Whatever decisions are eventually taken at the global level, access to quality health care is now high on the agenda of many governments from the South. Onward, thus, for universal health coverage in Africa too.

More attention to Universal Coverage from the CoPs

UHC has been a priority topic for HHA communities of practice since their inception, but now seems an opportune moment to spell out their contributions to the UHC agenda for the future. HHA set up CoPs to meet a pressing need: to consolidate good practices and tacit knowledge related to health care financing in Africa, both for the benefit of countries, but also among national and international experts. This consolidation could be measured by the number of experts who understand and use these best practices, both in terms of volume (inclusion of new experts and more sharing among different profiles) and in terms of quality (boosting individuals’ knowledge). The CoPs’ theory of change is that this consolidation takes place via the exchange, co-production, systematization and dissemination of knowledge on a set of technical practices. The fact that CoPs are growing steadily (the PBF CoP for example now has more 1,000 members) confirms that experts feel to the need be part of a network in order to better understand and stay on top of health financing issues.

The CoP contribution: the strength of the collaborative model

Our personal experience as facilitators has definitively convinced us that through their open, collaborative and facilitated way of functioning, CoPs are making a real contribution to the universal coverage agenda.

This contribution is happening in several ways.

First, CoPs facilitate the dissemination of knowledge generated by the numerous actors contributing to the global agenda of UHC, both from within and outside the CoPs. This sharing of information happens through our online platforms but also and perhaps more importantly, at the face-to-face events that we organize. An excellent example is the conference that the Financial Access to Health Services CoP will hold at the end of November in Ouagadougou: in partnership with researchers from the North and from Africa, a high quality conference is currently being prepared. An increasing number of actors are also inviting us to their own events or workshops so that we can share our observations and knowledge, but also help them more widely disseminate the results of their own activities (for example, the Financial Access CoP is a consultative member of the regional technical support committee for extending universal health coverage in UEMOA member states).

A second, and perhaps more original contribution is the collaborative dynamic of CoPs that allows us to “tap into” the hundreds of brains ‘connected’ to our platforms. In ICT terminology today this is called Model 2.0 or more specifically ‘crowdsourcing’. Through exchange and debate, CoP members can contribute to the identification of good practices (in terms of design and implementation of financing schemes in particular). Ensuring dynamic interaction is critical here, whether online or at a workshop, and the facilitators’ role is essential to distinguish between opinions and facts, between hypotheses and evidence.

Our many experts, by their very involvement ‘on the ground’ (in ministries, health facilities, support units, …) play a key role in enlightening the international community on feasibility, or the results observed in their country. Their proximity to operational implementation provides a ‘reality check’ for major international and national declarations. The lively online discussion in late 2012 on UHC was an excellent example of this feedback. At the end of the day, we are looking for results and not just lofty rhetoric. In Africa, these implementation issues remain a major bottleneck.

A multi-country study is launched

Beyond online discussions and this blog, certain CoPs are undertaking more ambitious projects. Two CoPs, Financial Access and PBF, have joined forces to conduct a descriptive exploratory study in 12 French-speaking African countries. The project has been made possible through French funding (Muskoka Fund), with additional support from the NGO Cordaid. The research will map the health financing schemes in place in these countries to better understand their complementarity, and also their overlap, in order to shed light what has become an opaque tangle of health financing. This multi-country research project is using an innovative collaborative model, and will be presented in the coming weeks on Health Financing in Africa.

Your participation

CoPs have proven that they have their place alongside traditional actors like Ministries of Health, international and bilateral agencies, NGOs and academic institutions. We are convinced that they can contribute in a very positive way to the universal coverage agenda, if they receive the support they deserve – from sponsors, but also from their members.

Last but not least, we want to make use of the opportunity to remind you that Health Financing in Africa is the blog of all members of ‘Financing CoPs’ of HHA. So if you want to submit a draft, don’t hesitate. In 2013 and 2014, we will be especially keen on receiving information on progress of UHC in your country, the challenges you face in your country, and the implementation process.

Notes:
(*)    CoP Financial Access to health services: Yamba Kafando, Allison Gamble Kelley, Isidore Sieleunou; CoP Performance-Based Financing: Nicolas de Borman, Serge Mayaka, Bruno Meessen, Emmanuel Ngabire; CoP Evidence Based Planning and Budgeting: Nadège Ade, Jérôme Pfaffman;
(**) More information on this meeting will be shared later.

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.

Fahdi Dkhimi, Maymouna Ba and Kadi Kadiatou

From 24 to 27 September 2012, Financial Access to Health Services Community of Practice organized, in collaboration with the Ministry of Health of Morocco and JLN network, a workshop in Marrakech. In this blogpost, three members of FA CoP get back on the event. This blog post was also published as an editorial in the journal “Global Health Promotion”.

While most everyone today agrees that countries should begin moving toward universal health coverage (UHC), how to practically implement this worthy ambition remains less than clear. One of the major challenges is to strengthen equity in health financing, and more precisely, to improve access to healthcare for the poor. For many countries, particularly low-income countries, the access of the poorest to good quality health care remains a distant dream. If the problem of ensuring adequate resources is important, the issue of knowledge management is also crucial. The implementation of many initiatives is hindered by inadequate knowledge sharing, which leads to repeating the same errors in different places. Hence the idea to create effective platforms for the production and sharing of knowledge, known as communities of practice.

The ‘Financial Access to Health Services’ Community of Practice (CoP FAHS) is one such innovative effort in Africa. Its objective is to promote the exchange and coordination among actors working on the issue of health financing and access to care. This CoP also aims to promote better consideration and use of evidence in the policy-making process (1). It largely operates through virtual interactions among its 400 members, but also through periodic face-to-face encounters at workshops organized around specific themes.

In September 2012, a workshop organized by the CoP FAHS was held in Marrakech, in collaboration with the Joint Learning Network (JLN) for Universal Health Coverage (funded by the Rockefeller Foundation, among others) and with a strong partnership and investment from the Ministry of Health of Morocco. The purpose of this meeting was to bring together a wide range of actors, from policy makers, to scholars and implementers, as well as members of the JLN network or the CoP, to address a key issue for achieving universal health coverage (UHC): health coverage for the poorest.

Ninety participants, including 11 country delegations took part in the meeting that had a number of innovative aspects: bilingual (French- English), working groups between peer countries, flexible organization of the 3 days, and content constantly being adapted to the needs of participants. But the most remarkable innovation was undoubtedly the workshop’s organization of a field visit - with strong support from the Ministry of Health of Morocco - to three sites where RAMED is being implemented, the Medical Assistance Program for Moroccan citizens identified as ‘poor’ or ‘vulnerable’. This “hands-on” aspect of the workshop has fueled in-depth exchanges and reflections on the challenges faced by African countries in the implementation of pro-poor strategies and medical assistance. It also gave the host country the opportunity to obtain the views of an expert panel on the RAMED, a program which began the crucial phase of nationwide scale-up in April 2012.

Beyond such positive feedback, the workshop’s theme - how to reach the poorest - is revealing of the magnitude of the task facing the CoP in the near future if it is to truly unleash effective knowledge sharing that informs and shapes the policy-making process (2). The key challenge remains its capacity to open up an area of health that has traditionally operated in a silo; one that has had great difficulty in incorporating multisectoral approaches. Even the process of selecting participants for this workshop demonstrated this problem: there was an overrepresentation of personnel of the ministries responsible for public health, whereas the organizations of civil society and the private sector, as well as other administrative services involved in reaching the poorest were virtually absent.

This lack of heterogeneity has introduced a bias in the technocratic thinking on the issue of access to care for the poorest. If the technical problems - the resolution of which is necessary but not sufficient in our opinion - have been widely discussed (identification of the poor, registration of beneficiaries, funding assistance, etc.), the presence of actors working in other spheres not related to health, especially the representatives of the poorest themselves, was missing in the debate, making it impossible to face up to structural issues in which inequalities in access to health care and in access to public resources find their roots.

The issue of access to care for the poorest is a major challenge for African health systems in their ambition to reach the UHC. Disparities in access and use are indeed a reflection of power dynamics that perpetuate structural inequalities of distribution of resources within a society and generate social determinism to access to care. These processes have been particularly highlighted by the work of the Commission on Social Determinants of Health, through its Social Exclusion Knowledge Network (SEKN) (3). This determinism plays full even when alternative mechanisms of financing health care are implemented - exemption, grant, gratuity, etc. - and partly explains the mixed results produced by these initiatives (4), see also Health Inc Research Project. A more structural analysis and a multi-sectoral approach is needed to understand all of the issues relating to access to health care for the poor and provide an effective solution.

Challenges that must be met successfully by the CoP will therefore be to become available to other sectors, other actors beyond technicians and experts in the field of health. It is on the basis of this capacity of the CoP to open up that it will be in a position to make a difference and provide opportunities for its members to leave the debates yet too restricted to technical issues, and which often cause erratic political processes (5).

References
1.     Meessen B, Kouanda S, Musango L, Richard F, Ridde V, Soucat A. Communities of practice: the missing link for knowledge management on implementation issues in low-income countries? Trop Med Int Health. 2011; 16(8): 1007–1014. doi:10.1111/j.1365-3156.2011.02794.x;
2.     Groves T. Development of health systems and universal coverage should be evidence based, says WHO. BMJ. 2012; 345 (2): e7530–e7530. doi:10.1136/bmj.e7530;
3.     Popay J. Understanding and tackling social exclusion. J Res Nurs. 2010; 15(4): 295–297. doi:10.1177/1744987110370529;
4.     Babajanian B, Hagen-Zanker J. Social protection and social exclusion: an analytical framework to assess the links. London, UK: ODI; October 2012: 12. Retrieved from http://www.odi.org.uk/publications/6889-social-protection-social-exclusion-design-analytical-framework;
5.     Mckee M, Balabanova D, Basu S, Ricciardi W, Stuckler D. Universal Health Coverage : A Quest for All Countries But under Threat in Some. Value in Health. 2012: 1–7. doi:10.1016/j.jval.2012.10.001;