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