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.

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.

Jean-Benoît Falisse

We continue our exploration of community participation in Africa, 25 years after the Bamako Initiative. Dr. Canut Nkuzimana is a member the CoP Performance Based Financing since its inception. He worked with the Ministry of Health of Burundi in the late 1990s before joining Cordaid. He had the opportunity to participate in the set-up of the first health committees of Burundi and in the development of performance-based financing (PBF) initiatives in the country. More recently, he has been active in launching a new "community PBF" project. Here I chat with him about his experiences.

You had the opportunity to establish health committees in southern Burundi on behalf of Memisa (future Cordaid). How did that happen?

In February 2002, when Memisa recruited me to pilot its primary care health project in Makamba, the region was still a war zone. More than 40% of the population of the province lived in internally displaced people’s (IDP) sites. These sites where places of poverty, disease and abuse of all kinds; they were located around the health centres and the schools. Some of these facilities had even stopped working in order to shelter those displaced by war. In the health centres that were still functioning, the management was calamitous; qualified staff had often deserted the place and the remaining staff members were running the centre as they liked. There was no follow-up. My project aimed to revive the activities in health centres and to develop nursing stations. The idea was to allow people to have access to a minimal package of services: immunization, family planning, and curative services.

At the time, the WHO and the Ministry of Health had begun to promote the idea of organizing the population to be the co-managers of their health services. The context of Makamba made us act. The population would be the co-manager of the aid it received. To get there, sensitization activities were conducted for the administrative authority (on the relevance of the project), the population (on the importance of management and accountability) and the staff of health centres (on the need to work with the population). After these sessions, we organized a general meeting in each health area, in collaboration with the local and the health sector (soon to renamed health district) authorities. The population received a preliminary explanation about the nature, the mission, the composition and the responsibilities of the health committees before they elected their members.

The idea was that the inhabitants of each “hill” (“colline”: the lowest administrative level in Burundi) of the health area would elect two people (a man and a woman, from two different sides of the hill) on the basis of their integrity, dedication to the cause, and willingness to represent them in the health committee. Once elected, the health committee members would set up an executive office. The elections were followed by training and a long monitoring process. The population was proud to participate in the management of health centres and it was a starting point for organizing effective community participation.

Was it easy to implement? Did it work?

In 2002, the health committee strategy was obvious and easy to implement because: (1) the population was living in IDP sites and was therefore easy to gather, (2) the crisis made the population particularly sensitive to health issues and, (3) as a donor we were influential in the health facilities and population.

The “community strategy” also allowed us to work on the flexibility and integration of various community health workers who had been working in solo and without funding until then and were only used occasionally, during epidemics.

Finally, as structures for community dialogue, the health committees helped us in identifying and monitoring the care of vulnerable people (“indigents”) by health centres and their referral to the hospitals.

In 2006, free health care for pregnant women and children under five was put in place in Burundi. Various funding initiatives based on performance were also introduced at that time. What is the role of community participation in those schemes?

On free health care first; the role of the health committee is to clarify these aspects of maternal and child health and to inform the population of the MoH guidelines. It is the health committee that must explain to the households the need to register births and bring those documents at the health facility. The health committees allow better monitoring to ensure that the system is fair and that everybody is covered. It defends the rights of the beneficiaries in the health area.

Regarding PBF, the interaction with the community is at three levels. First, the health committee is the co-manager of the health facility and participates in its development plan, which is the tool for negotiating the PBF contract. Second, there is the establishment of a system of contracting community health workers. Finally, the PBF system will hire local associations to participate in the audit of the health facilities (community assessment).

There has been a “community PBF” experiment in Burundi; could you tell us what it is?

Like the “clinical” PBF that subsidizes the services provided by health facilities, the community PBF subsidizes the results achieved by community health workers (CHWs). The activities of these agents focus on three dimensions: sensitization for the use of services, the recovery of dropouts (vaccination, tuberculosis, ART, etc.), distributions of nets, contraceptives, etc. (see table below for a list of the subsidised indicators - $1 = BIF1530 ).

Wouldn’t your reflection on the limits of voluntary work equally apply to the health committees?

For health committees, the issue of volunteering was somehow overcome through the implementation of the PBF. We felt that if the health centre pays benefits to the members of its health committee, the health committee may lost its representative dimension (the motivation to be elected would be biased). Therefore, we designed a formula that recommended to health facilities to assist the functioning of the health committee via a contribution of 5% of what they receive through the PBF. The amount that is given is not a premium; it is a contribution to the operation costs. The COSA can buy pens, paper, binders, etc. And whether it wants to pay its member a drink on meeting day, it is up to it. Revenues that are generated at the health centre are in a sense a community input, so it makes sense that some of that money is used for the proper functioning of the co-managing unit of the community health centre.                                                                                                                                                                                              Group of community health workers (Province Makamba) Photo: Korachais     
Does community participation in health have a future in the Great Lakes region?

Yes, but it starts with peace. Without it, it is difficult to continue to work with communities in the long run. At the same time, in our context, the community approach provides an opportunity to bring people together, to unite them around a common vision/interest. Through “Community PBF”, there is even a possibility to inject some funds and organize the community level. A community that is occupied, works, and has a common interest, is much less likely to be manipulated or to return to violence. The second condition is that the health systems understand the importance of the community and plans some funding of this level. It is indeed necessary to organize training for these community actors.

 Manuela De Allegri and Isidore Sieleunou

Manuella De Allegri (University of Heidelberg) and Isidore Sieleunou were in Berlin last week at the GIC Forum on Health and Social Protection. They enjoyed this conference on Universal Health Coverage, but were really surprised by the fact that user fee removal was not discussed.  An oversight or a bias?

Last week, we had the opportunity to take part in a Forum organized by the German Cooperation on Social Health Protection, the title being Universal Health Coverage: From Promise to Practice. The Forum gathered international experts across the policy, the implementation, and the research arena. Health financing “veterans” of the level of David Evans, Joe Kutzin, and Tim Evans were invited to meet experts working for the German Cooperation, their policy and implementing partners across the world, and a selected number of researchers to discuss the challenge of moving countries towards universal health coverage (UHC) and possible strategies towards this end.

The forum provided the opportunity for extensive exchange, with provocative discussions and innovative thinking characterizing the two days spent in Bonn. We definitely took home a number of inspiring ideas. Notwithstanding the number of very interesting sessions, however, we were left to wonder how it was possible to spend two days discussing UHC and not once mention user fee abolition. The forum simply overlooked the experience of countries which have recently implemented user fee abolition as an initial step towards UHC. 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.

In her key note speech, Dr. Speciosa Wandira-Kazibe, the former Vice President of Uganda, repeatedly stressed that UHC is all about responding to increasing demands for better health services, no matter what path towards the goal is chosen. She insisted on keeping open to all policy options, adjusting to the specific circumstances of each country.  Therefore, we later found the omission of user fee abolition somewhat surprising considering that the evidence on the impact of user fee abolition on improved access to health services and financial protection is by now quite substantial. While it is true that some countries might have rushed into user fee abolition without carefully preparing its implementation and might have therefore encountered problems to keep up the promise of improved access to quality services, other countries, such as Ghana or Burkina Faso, have successfully worked on the careful progressive implementation of user fee abolition (or reduction, as for Burkina Faso) for selected services and/or population groups. Interestingly, such countries have explicitly implemented user fee abolition/reduction with the intent of advancing population coverage on a limited spectrum of services, while preparing further-reaching health policy reforms aimed at advancing progress towards broader UHC goals.

We were left to wonder what could motivate a community that gathers to discuss strategies towards UHC to overlook user fee abolition. One thought that immediately comes to mind is that discussions on UHC are largely dominated by what sociologists would define as culturally dominant paradigms. The concept of cultural hegemony refers to how power is indirectly reflected in the ideas that we, as society, hold to be the most prominent. It is to say that the ideas of those who enjoy power in a community receive more attention and ultimately end up being the ideas that the collectivity holds to be true. User fee abolition has largely emerged as an endogenous movement within African states, one that only recently gained explicit support from international UN agencies and the World Bank. As such, one could see it as a movement that is simply not part of the dominant paradigm, as African states are not known to be the ones who hold the most power in the international arena. One could further postulate that the natural consequence is that user fee abolition is not deemed to be worth of the same attention as vouchers or conditional cash transfers, strategies to UHC largely supported by the exogenous international community. The discourse at the forum might have simply reflected the distribution of power at the global level, with some reforms endogenous to African states, such as user fee removal, receiving less attention than those widely promoted by the international community.

Moreover, the forum devoted ample space to discussions of the link between evidence and policy, paying specific attention to the function of knowledge brokerage. The community at the forum amply engaged in discussions on the role of the encounter between research and policy and on the need for knowledge brokers to facilitate this encounter, by enhancing two-way communication between the two. Still, we are left to wonder, how can effective knowledge brokerage take place in a context dominated by cultural hegemony? How do we even start discussing the path towards UHC in a fair way if the options we bring to the table are only the ones deemed worth of discussion within the framework of a dominant paradigm? Are we doing justice to UHC if we overlook a selected set of endogenous strategies?

We have no answer, but surely many questions to reflect upon as researchers committed to the production of the evidence for policy, beyond power relations and political concerns. Personally, we are looking forward to the conference organized by the Financial Access to Health Services Community of Practice in November in Ouagadougou. We look forward to the opportunity to discuss financial strategies to enhance access to maternal and neonatal health services, beyond dominant paradigms of what may be deemed and what may not be deemed worth our attention as we all strive together towards UHC.

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)

Bruno Meessen


In this blog post, Bruno Meessen (ITM, Antwerp) revisits the gaps in the implementation of fee exemption policies in numerous African countries. He attempts to draw useful lessons for the universal health coverage agenda, for African governments, the international community and researchers. 


In 2009, at the request of UNICEF, I was fortunate to be able to coordinate a study on fee exemption policies in 6 African countries. The results were published in a supplement of Health Policy & Planning, alongside other articles on the same topic. Our multi-country study had relatively modest ambitions: we were not trying to document the impact of these policies, but rather try to understand to what extent their formulation and implementation were based on good public policy practices. Overall, our evaluation was not very positive. While the study confirmed the good intentions of country leaders to take strong measure to reduce financial barriers, it highlighted the precipitous manner in which such measures were put in place without adequate preparation (in terms of time, financing, accompanying measures, and technical expertise) for national technicians to ensure that these policies were well conceived and well implemented. We expressed concern about the consequences these weaknesses would have on the policies’ efficacy and sustainability.

This study had at least one tangible effect: it made it clear that a lot of work remained to be done in terms of sharing and spreading knowledge regarding the implementation of health financing policies. At the dissemination meeting for the study in New York, the idea for creating a community of practice around fee exemption policies was launched. In due time, the Financial Access to Health Services CoP was launched. You are likely already familiar with its work if you follow this blog.

Implementation of fee exemption policies: what we know in 2013

The topic of formulating and implementing fee exemption policies has been relatively intensely researched in the past few years. This is not only the case for the FAHS CoP as a group (note the Bamako CoP workshop in 2011, but also a forthcoming conference in Ouagadougou in November 2013), but also for several teams of researchers.  Let me specifically mention recent studies by Valéry Ridde (University of Montréal) and Sophie Witter (University of Aberdeen), two prolific authors whose work also contributed to the multi-country study.

In a very recent edition of Afrique Contemporaine (in French), the results of a mixed method research led by Jean-Pierre Olivier de Sardan and Valéry Ridde were published. The supplement reports on the different observations made by research teams, notably LASDEL, on fee exemption policies in Burkina Faso, Mali, and Niger. Several noteworthy articles include one on the perceptions of various actors in Mali, a mapping of fee exemption policies in West Africa (showing that all countries have them), and a study from Niger investigating the problem of decapitalization in health centers.

The introductory synthesis is entitled “Fee exemptions in Burkina Faso, Mali and Niger: public policy contradictions.” This title reflects the overall tone of the supplement. Here is an excerpt.

Fee exemptions are decisions taken at a national level, defended as sovereign, and implemented by national technicians without any particular external assistance, something rather rare in the history of health policy. But these reforms have been made hastily. The decision has been political rather than technical, announced suddenly and publically, taking not only field technicians but also those in the Ministry completely by surprise. 
                                                                                                                                               (Olivier de Sardan & Ridde 2012 - our translation)

A few months earlier, Valéry Ridde, Ludovic Queuille and Yamba Kafando had just finished the final report of their project, “Capitalizing fee exemption policies for health services in West Africa.” This project is worth mentioning for several reasons: beyond the knowledge that it generated, it had the merit of being based on country experts (Ministry of Health professionals, researchers, and NGO experts involved in fee exemption programs). The transversal study centered on 7 countries (Benin, Burkina Faso, Ghana, Mali, Niger, Sénégal et Togo ). It also focused on implementation. 

The book’s tone is more positive than the supplement cited above. The synthesis chapter, which is also available in English, identifies for six of the countries studied, the major problems encountered during implementation but also the innovations. An excerpt:

"While the principles underlying these policies appear to be well appreciated, health workers did not hide their dissatisfaction regarding the policies’ implementation. In Burkina Faso, they complained of a lack of medical and technical supplies, while in Senegal and Niger the complaints were regarding significant delays in reimbursement of free services provided to patients. Finally, in most cases, workers were calling for financial bonuses to compensate for increases in their clinical or administrative activities resulting from user fees exemption policies. These financial aspects of bonuses for health workers were not taken into account in any of the policies."
                                                                                                             (Ridde et al. 2012)

Elsewhere in 2012, Sophie Witter published a study on the fee exemption policy for Caesarean sections and for children under five years old in Sudan, a country little documented in international health. Her study once again highlights major weaknesses in implementation.

"The fee exemption policy for Caesarean sections and for children under five years old, launched in 2008, clearly suffered from a number of constraints that led to uneven and often poor implementation. Notable among these constraints is a lack of adequate financing and clear implementation guidelines."   
                                                                                                                                                                                                      (Witter et al 2012)

Let me make four comments before giving my own read of the situation. First, one can observe that the general tone of these studies on fee exemptions remains relatively positive. Neither the authors of these studies nor I intend to discredit these national policies. Second, these studies show that there is a certain heterogeneity in countries’ experiences: countries that have had better implementation than others have shown some good results. Third, when one identifies weaknesses in either formulation or implementation, one should not write those policies off entirely. We know that certain policies that have begun badly have later been reformed to better reach the most vulnerable. The example of Burundi – which combined its fee exemptions with its performance-based financing program– is the best known case. Fourth, it appears that countries having launched their fee exemption programs later have been able to benefit from recommendations to better prepare for the policy. This is certainly the case of Sierra Leone, even though challenges remain. 

All of that said, here we are all the same with a sample of 11 documented country experiences telling the same story: fee exemption policies in Africa over the last 10 years have been public policies launched on presidential initiative, using national resources, but formulated in haste without adequately and rigorously taking into account technical and operational considerations. Those that are under-financed are nonetheless in danger. 

 What has changed at the country level

It is important to note that these policies have marked renewed initiative among African presidents and governments to re-engage in the health sector. In a number of countries, other than health personnel salaries, the State had basically been absent in the health sector for two decades; cost recovery, the rise of the private health sector, and international assistance having left the impression that health financing could manage without public funding (well, it is also true that, to put it bluntly, State coffers were empty).

Today we are coming full circle: user fees – which will likely continue to play a role despite wide criticism – have shown their limitations; the rise of the private health sector in many countries has been poorly regulated by the State, and the global financial crisis in wealthy countries hardly paints a hopeful picture for international assistance.  But more fundamentally, economic growth is creating new financing possibilities within public budgets across the continent.  

We must, however, ensure that this re-engagement by national leaders happens in the most productive way possible, with budgets matching not only declarations, but technical rigor and long-term vision. It should be possible to build on the pledges made jointly by health and finance Ministers in Tunis in July 2012. We can also make the most of the international interest and support for Universal Health Coverage. But to build the future, we must not forget lessons from recent experience. 

Two reflections for the political agenda for UHC

A first lesson is for the ears of political leaders (if they read us!): remember that haste is a resource to use with caution when it comes to health financing. Leadership and boosts in momentum are welcome, but should not compromise the initiative itself, nor all of the health system strengthening efforts that have preceded it. UHC won’t be built on a few announcements, but through perseverance.

The lack of dialogue that accompanies political precipitation breeds unnecessary antagonism. It would be a shame for those who work tirelessly to strengthen health systems – whether they are frontline workers, implementers at the regional or national level or advisors – to become a force of opposition to UHC. The lively debate within the PBF CoP after the UN General Assembly’s resolution on UHC reflect this reality.  

There is also a lesson there for international actors advocating for UHC. It is perhaps the time to re-evaluate the relative effort you are putting into advocacy versus actual technical assistance.  Our impression is that advocacy predominates when it comes to UHC: while Twitter is buzzing, people are mobilizing in Beijing, and at the UN they are promoting UHC, the aid community is providing precious little support to UHC on the ground. We should thus not be surprised as presidents are getting on the bandwagon and the political machine is activated that they “put the cart before the horse.”

Focusing exclusively on advocacy for UHC makes sense maybe for middle-income countries – they have the financial resources and technical capacity in line with such ambitions. But in poor countries, advocacy alone is problematic. And yet it is virtually impossible to compartmentalize the world when it comes to advocacy, messages pass far and wide. 

You get my point: we are arguing for an approach with a much more context specific analysis of the challenges many African countries are facing, especially those where governance is still being strengthened. We are not, however, advocating for some super-agency for UHC; that model is outdated. We are convinced that appropriate assistance should be based on a more collaborative model that builds on the growing expertise present on the continent, such as HHA has promoted and is being implemented through communities of practice. We would be happy to see more collaboration and support, especially from the UHC flag-bearing institutions.

Ideas for researchers

Our third point addresses researchers. Thanks to your hard work, we know much more about the last ten years’ experience with fee exemptions in Africa. Of course, many questions remain, but it seems fair to say that at least in terms of retrospective studies on the formulation and implementation of country fee exemption policies, we are reaching a data saturation point. 

For some observers, these fee exemption policies are just a step on the path toward UHC. Shouldn’t that point to another research topic: how have these policies evolved and are they in-line with UHC objectives; are they actually an effective starting point on the road to UHC?  

I see at least two possible directions.

It would be interesting to pull together knowledge on the policy process, especially on the dialogue between the political and technical levels. Are they eventually able to transcend their initial lack of dialogue? Have presidents drawn lessons about the importance of this dialogue? Or on the contrary, are the same errors being repeated? If the same problems persist, what are the determinants of such political haste? What options exist for actors wishing to improve these processes? What are the lessons for the next phases toward UHC?  

We can also identify the stakes when it comes to policy design. Researchers really need to help us all reflect on how these fee exemption initiatives – often multiple in the same country - relate to other financing schemes to form a coherent strategy that provides health coverage to all. In many countries, there is a complex mix of coverage schemes: public financing (traditional or PBF), health insurance for civil servants, mutuelles for those in the informal sector, and various fee exemptions for different population groups, age ranges, health problems, and even treatment regimen! For reasons of efficiency, equity, not to mention limited available resources, it becomes critical to better harmonize health financing schemes. We could begin by documenting the situation at the country level and by identifying some potential solutions.  Can any of you help countries in this way? It will certainly be a top priority for the CoPs in 2013.

Translation: Allison Kelley

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