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
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
