In this blog post, Isidore Sieleunou (co-facilitator of the "Financial Access to Health Services" Community of Practice) summarizes some of the main messages of the conference which took place in Ouagadougou (25-28 November 2013). The event was co-organized with the FEMHealth Consortium and the universities of Heidelberg and Montreal. This blog post is cross-posted from the IHP newsletter.

In 2011, the Financial Access to Health Services Community of Practice (FAHS CoP) held a workshop in Bamako to discuss the formulation and implementation of maternal health fee exemption policies. At the end of the workshop, a research agenda was put forth. Two years later, the FAHS CoP, alongside several academic partners, gathered again to take stock, this time in Ouagadougou, Burkina Faso.

A conference to assess the effectiveness of fee exemption policies

This time, our focus was on evaluating the effectiveness of these policies. Have they had a positive impact on maternal health? Have they had a protective effect on households against catastrophic health expenses? How well have they been integrated into health systems?

Plenty of stakeholders showed interest;  more than 120 participants gathered in Ouagadougou:  high-level decision makers, front line implementers of fee exemptions, researchers, and representatives of both bilateral and multilateral, governmental and non-governmental institutions.

It turned out to be an exciting week of activities structured in an innovative 1+3+1 format (field visit on the first day, then 3 days of presentations and debates, and a training session on the last day, with each person free to choose the program of events that suited him/her). A clear highlight was the fact that the French Minister delegate for Development, Monsieur Pascal Canfin, and the Minister of Health from Burkina Faso, Monsieur Léné Sebgo, presided over the conference’s closing session – a major political recognition for our CoP! 

Policies that are working

For more than 10 years now, numerous African countries have launched fee exemption policies in an effort to achieve the MDGs, but also to reduce out-of-pocket health expenditures.

Content wise, these policies vary from one country to another. The policy in Benin, for example, covers only Caesarean sections, while Burkina Faso’s policy extends coverage to all services during the pregnancy and neonatal period, albeit with a patient co-payment equivalent to 20% of direct costs.  In between these two cases, there is a range of combinations.

A lot of the discussions in Bamako focused on the fact that most of the policies were hastily implemented at the national level, without the benefit of a pilot phase, without adequate accompanying measures, and especially without systematic monitoring and evaluation of the impact.

This situation has posed plenty of methodological challenges for researchers, but nonetheless, a number of research programs were undertaken, and against all odds, several research teams managed to document these policies. In recent years, managers and implementers of these policies have accumulated significant tacit knowledge.

The study results presented in Ouagadougou are impressive, and show that exemption policies and subsidies have:

• Resulted in higher utilisation of maternal health services, such as prenatal care and assisted deliveries;

• Shown that insofar as many wealthier women already sought out such maternal health services, the rise in utilisation is particularly obvious for poorer women. This is especially documented in the cases of Burkina Faso and Morocco; 

• Led to better access to Caesarean sections with a reduction in post-Caesarean mortality and a significant reduction in unmet need for obstetric services in Benin, Burkina Faso, Guinea and Morocco (though in terms of the quality of the services delivered, there is some variance, as shown by a FEMHealth study in Benin);
• Lessened household out-of-pocket payments for maternity care in Burkina Faso and in Morocco.
  

We noted the interesting effect on women in one district in Burkina Faso of strengthening their decision-making power within the household (by eliminating the financial worry and providing a clear care-seeking path). Another effect was faster health seeking behaviour among women and their children.

But of course, difficulties remain, and some of the results are mixed. One study documented the problem of health worker overload in Niger. It also appears that in Benin richer women benefit the most from the free Caesarean section policy.

These challenges are most likely not inherent to the fee exemption per se, but to deficiencies in the policy’s formulation and/or implementation within the health system. Implementation challenges are unavoidable, though, and countries are learning as they go.

The clear success of the policy in a country like Burkina Faso is also directly linked to its monitoring and evaluation – its ability to produce data and use these data to adjust policy implementation accordingly.

What is in store: a new generation of more targeted fee exemptions?

In my view, the debate should no longer center on whether one is “for or against” fee exemptions, but should take a country-by-country approach instead.

In countries where fee exemptions and subsidies are working -  if the rate of assisted deliveries is high (Burkina Faso and Morocco) - or in a country where those rates were already high (Benin), it is probably time to think about the next step, “second generation models”, where several financing schemes are used in tandem to address a specific challenge.

One example is the inadequacy of exemption policies to reach some vulnerable population groups, who may face other as yet insurmountable obstacles to actually reaching a health facility. I still remember the words of a doctor from Kaya regional hospital during the field visit; “I cannot understand: services are free, but women are still not coming.” 

Given the example of the success and effectiveness of “vouchers programs” on utilisation, quality, and equity (an example from Kenya was presented at the conference), it could be interesting, for example, to pair a fee exemption with a “voucher” for the poorest women. Such a combination could strengthen fee exemption policies and make them more effective in terms of reaching the poorest and most vulnerable groups.

This conference also sounded like a (necessary) response to the recent Bonn forum on universal health coverage (UHC). During this three-day forum, a wide range of strategies targeting all dimensions of UHC (population coverage, access, and financial protection) were discussed from efficient service purchasing to insurance systems, from cash transfers to vouchers … just no mention of user fee abolition. UHC is all about responding to increasing demands for better health services, no matter what path towards the goal is chosen, keeping open all policy options, adjusting to the specific circumstances of each country. Exemption/subsidy policies are proven and cannot be left out of instruments for UHC in Africa.

In their closing words at the conference, the French Minister delegate for Development and Burkina’s Minister of Health paid tribute to the CoP’s dynamic approach, emphasizing the importance of substantive exchange among different knowledge holders in order to overcome challenges and succeed in health system reform.

Thierry van Bastelaer*

On May 23, 2013 a group of researchers affiliated with the Health Working Group of the Microinsurance Network were hosted by Consultative Group to Assist the Poor (CGAP) to share the results of their recent work on various facets of micro health insurance. In this blog (also published by the CGAP), Thierry van Bastelaer summarizes the highlights of this meeting, and reflects on the role of micro health insurance in the transition to universal health coverage.

The in-person and virtual audience engaged the presenters in a lively debate about a number of critical issues in the field, including why uptake of health insurance remains low, the relative importance of covering inpatient and outpatient care, the role of subsidies, the commercial sustainability of micro health insurance, the central importance of the quality of care made accessible through insurance, and the respective roles of the public and private sectors in providing insurance coverage to low-income families. 
 
That last point, in particular, was discussed at length based on an example from India. It appears that the large, publicly-funded RSBY scheme is crowding out Indian microinsurance providers when offered in the same markets. This observation led to the most fascinating question of the event (thank you, as always, Peter Wrede!): is there a future for micro health insurance?  Is it destined to go by the wayside as governments take on an increasingly larger share of the burden of providing coverage to their populations? Should it?

Like every other industry, microinsurance is—at least partially—concerned with its own survival. It can sometimes forget, however, that it owes its existence to failures in public (and sometimes private) insurance markets. As these failures are addressed and micro health insurance clients are increasingly covered by public insurance, there will come a point where all that’s left for the industry to do is acknowledge its role in this transition, and gracefully bow out. But we’re not there yet—for at least five reasons.

First, not all governments have access to resources like those of the Indian government, which is in essence financing the near-full cost of inpatient health insurance to more than 30 million of its Below Poverty Line (BPL) citizens.  Although that’s only about 10% of the total BPL population in India, the government appears committed and financially able to significantly expand that percentage over the coming years.  For most developing country governments, however, limited financial (and sometimes political) capital would make very difficult—at least in the short and medium term—to finance the cost of care for substantive numbers of people. While these governments are addressing these constraints, microinsurance can play a significant role in providing affordable solutions to low-income families, either by providing coverage in areas where governments have not yet reached, or by complementing basic public coverage.
 
Second, to the extent that micro health insurance can help build large risk pools, it paves the way for governments to channel their resources (in the form of premium or back-office subsidies) toward low-income families in these risk pools, faster and at potentially lower cost than through financing the full cost of care for these families.
 
Third, because of the critical need to reduce costs to levels that make their products affordable for low-income families, micro health insurers are continuously innovating to find cost-effective approaches to developing, distributing, and servicing health insurance products— innovations that governments intent on reaching the same populations may find useful to integrate in their insurance programs.
 
Fourth, while only governments have the ability to mobilize the resources necessary to finance large-scale coverage, there is no a priori reason (and little evidence) that they have a comparative advantage over the private sector when it comes to the two other segments of the health insurance value chain: underwriting and distribution.  In that respect, experiments in India and Nigeria with private underwriting and distribution of public insurance will soon provide critical information about how best to structure public-private partnerships along the health insurance value chain.

Finally, most governments committed to providing health coverage to their vulnerable populations will probably and rightly choose to start by offering a basic benefits package (accessible through public facilities) to the largest possible number of families. In this scenario, the most durable role for microinsurance may well be to offer a complementary add-on to public packages, either by providing access to benefits not included in these packages, or by offering options to seek basic or advanced care in private facilities. 

In any event, I expect that the microinsurance industry will, at some point in the not-too-distant future, realize that its growing irrelevance is the unmistakable mark of its success. In the meantime, micro health insurance can and should continue to provide health coverage options to those families that cannot afford to wait for the public option to help them meet the cost of urgent medical care.

* Thierry van Bastelaer is Principal Associate/Economist at Abt Associates in Bethesda, MD, where he provides leadership in addressing a broad set of issues involving livelihoods, health, and protection from financial risk. His work includes identifying regional trends in community-based health financing and other forms of community insurance, and providing innovative solutions to problems of financial risk protection.

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;

Yamba Kafando


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)

From 24th to 27th September 2012 , the Financial Access to Health Services Community of Practice co-organized, with Ministry of Health of Morocco and JLN, a workshop entitled "Equity in Universal Health Coverage: How to reach the poorest" in Marrakesh, Morocco. The workshop gathered policy makers, scheme managers, agency representatives, scholars and members of parliament. At the end of the workshop, a declaration was issued. The declaration engages participants, not the agencies or governments they work for. It marks their personal commitment to work for better access to health services for the poorest in Africa. You also can adhere to the Declaration on our facebook page. Join the movement and make your own personal commitment, even the most modest one.


We, as participants of the workshop on “Equity in UHC: How to reach the poorest”,
We as members of the communities of practice affiliated to “Harmonization for Health in Africa”,
We as experts involved in health systems in Africa,

Are conscious of the deep inequalities in terms of access to health care in our countries,
Are conscious of the impact of these inequalities on the health of the poorest,
Are conscious that access to health care for the poorest is dependent on our health systems,
Are conscious that assisting the indigents, the excluded, the poorest of the poor is inscribed in our shared human dignity.

We are enthusiastic about the growing interest of the African States and their partners in their efforts to improve universal health coverage.
We consider essential that this interest be translated as rapidly as possible into actions and concrete measures in order to benefit the poorest.

Consequently, we commit to taking action personally:
By supporting the implementation of strategies to improve access to health care for the poor.
By building on and accompanying the mechanisms to extend universal health coverage.
Finally, by continuing to focus all our energy on facilitating equitable access to health care in our countries.

Issued in Marrakesh, Morocco, September 27th 2012.

Alex Ergo, PhD, Broad Branch Associates / Health Systems 20/20
alexergo@broadbranch.org

How does performance-based financing (PBF) – or results-based financing (RBF) – affect equity? This is difficult to predict, especially when equity has not been taken into account explicitly in the design of the program. In fact, the effect can go either way. On one hand, the introduction of financial incentives to boost performance can be expected to encourage providers to concentrate their efforts on those population groups that are most easily reached, which is likely to increase certain disparities. Indeed, the most deprived are typically not found in those groups. On the other hand, if community health workers benefit from the incentives, for example, it is possible that service utilization will increase in more remote areas, which could reduce disparities.

In reality, the only way to know what the effect of PBF is on equity is to measure it. This requires the inclusion of equity in the program’s monitoring and evaluation system. But before that, the program will need adopt a clear definition of ‘equity’, which involves the specification of three elements: the dimension of reference, the stratification variable and the normative criteria adopted:
- Which equity dimension is the program concerned with: equity in health results (e.g. life expectancy, mortality, morbidity), in health service utilization, in health expenditure, or in protection against catastrophic health expenditures, for example?
- Between which population groups are the health disparities most pronounced? In other words, which stratification variables should be considered: gender, age, geographical location, ethnicity or socio-economic position, for example?
- What is considered to be an ‘equitable’ situation: equality between selected population groups; utilization of services according to need...?

These two first steps – the definition and measurement of equity – are absolutely necessary to better understand the equity situation and how it is affected by PBF. They are nevertheless insufficient if we want to ensure that PBF has a positive effect on equity. For that, it is equally important to explicitly incorporate equity in the objectives, the design and the implementation of a PBF scheme. All of this should ideally be placed within a more holistic reflection on the financing of the health system.

The question then comes down to “how to define, measure and incorporate equity in a PBF scheme”? Many members of the Communities of Practice (CoPs) “PBF in Africa” and “Financial Access to Health Services”, even though they recognize the importance of taking equity more explicitly into account in their intervention, may not have the necessary knowledge or tools to do so. They may also be seeking opportunities to collaborate with other members of the CoP on this issue. More fundamentally, we need to recognize that relatively little is known today as far as the equity effects of PBF are concerned.

It is in order to respond to this need that we have just launched a working group “PBF and Equity” at a workshop organized by the two CoPs in Bujumbura, Burundi, on April 16-20, 2012.

This working group aims to assist the members of the two CoPs:
- To better understand the different approaches to measure and analyze equity.
- To better understand how these approaches can be used in the context of PBF.
- To identify the approaches that are most relevant in a given context.
- To develop strategies to better integrate equity into a PBF scheme.

More generally, the working group intends to play a key role in stimulating the thinking around equity in the CoPs. This will be achieved through various activities, including:
- The dissemination of tools and methods to measure and analyze equity.
- The dissemination of concrete experiences, with their respective strengths and weaknesses.
    o    What is already being done in PBF schemes?
    o    What can be learned from non-PBF programs?
- Discussions around specific questions relating to PBF and equity.

The working group can make use of a number of communication channels to implement these activities. To a large extent, these are the channels that are already being used by the CoPs: email, online discussions, newsletters, blogs, readers club...

The working group is open to any member of either CoP who has a genuine interest in the topic and who is willing to contribute to certain activities, based on his/her availability and skills. At least 20 members have already expressed their willingness to be part of the working group and to contribute to its activities. Clearly, it will not be possible to implement all activities at the same time. Activities will need to be prioritized. This exercise will be guided by the specific needs expressed by CoP members and by the preferences of working group members. For some of the activities, it will also be necessary to make sure that the required resources, both human and financial, are available. 

Initially, I will be happy to coordinate the efforts of this working group. I hope, however, that this task can soon be shared with or taken over by one or more active members of the group. I hope this new working group will be able, through its activities, to respond to the needs of the members of the CoPs, both in terms of knowledge and skills, and to encourage them to do whatever is needed to give equity the attention it deserves within PBF schemes. If you want to learn more about this working group and its activities, or if you are keen to join this initiative, feel free to contact me.