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Robert E.

Montreal University Hospital Research Centre (CR-CHUM), Canada!
No stance
n = 16 (30%)
Negative stance
n = 0
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Removing health user fees in sub-Saharan Africa: international debate, challenges of implementation, and health care seeking practices


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This poster was presented at the Canadian Student Health Research Forum held in Winnipeg in June 2014.

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Removing health user fees in sub-Saharan Africa: international debate, challenges of implementation, and health care seeking practices

  1. 1. Robert E.
 Montreal University Hospital Research Centre (CR-CHUM), Canada! No stance n = 16 (30%) Negative stance n = 0 Neutral stance n = 7 (13%) Positive stance n = 30 (55%) Nuanced stance n = 1 (2%) Intergovernmental Organizations 5 (incl. UNDP, UNICEF) 0 4 (incl. OECD) 7 (incl. European Commission, ILO, WHO) 1 (The World Bank) Government Agencies 6 (incl. Canada, USA) 0 1 (Sweden) 3 (incl. United Kingdom) 0 International NGOs 2 (incl. Gates Foundation) 0 0 6 (incl. Oxfam, Save the Children, World Vision) 0 Networks and Working Groups 3 (incl. The Global Call to Action Against Poverty) 0 2 (incl. The Global Coalition on Women and AIDS) 14 (incl. Commission for Africa, G8, People’s Health Movement) 0 Contact"! Emilie Robert is a Ph.D. candidate in public health at the University of Montreal. She is a senior fellow of the Global Health Research Capacity Strengthening Program (GHR-CAPS). She was granted a scholarship from the Faculté des Etudes Supérieures of the University of Montreal. Her doctoral thesis is supervised by Valéry Ridde, associate professor at the Department of social and preventive medicine at the University of Montreal.! Article 2" Objective:" To identify disruptions in health systems caused by user fee exemption policies (UFEPs) in sub-Saharan Africa.! Methods:" Scoping study based on peer-reviewed articles published in English or French, between 1998 and 2009, reporting original empirical data on UFEPs in sub-Saharan Africa, and mentioning pressures or disruptions in health system.! Analysis:" Content analysis based on WHO framework of six essential functions of health systems.! Article 1" Objective:" To determine to what extent a consensus exists among the various Global Health Actors (GHAs) on the issue of user fees in low- and middle-income countries (LMICs).! Methods:" Documentary study based on official and public position statements available on the Internet in English or French, published between 2005 et 2011, addressing the issue of development, poverty or healthcare in LMICs, and officially credited by a GHA.! Analysis:" Stakeholder analysis using a decision tree + thematic analysis.! Background" Paying for health care is an expensive reality for sub-Saharan populations, especially for the most vulnerable who can rarely afford it. This is why more and more countries in the region abolish health user fees for certain categories of population (e.g. pregnant women, children under five, etc.) or for basic health care. ! The objective of this thesis is to explore the issues raised by removing health user fees in sub-Saharan Africa, based on the conceptual framework for globalisation and population health by Huynen et al. (2005) (Figure 1). ! References" Huynen, M., Martens, P. & al. (2005). The health impacts of globalisation: a conceptual framework. Globalization and Health 1:14. doi:10.1186/1744-8603-1-14! Obrist, B., Iteba, N., & al. (2007). Access to Health Care in Contexts of Livelihood Insecurity: A Framework for Analysis and Action. PLoS Medicine 4(10):e308. ! Robert, E., Ridde, V., & al. (2012). Protocol: A realist review of user fee exemption policies for health services in Africa. BMJ Open 2: e000706. doi:10.1136/bmjopen-2011-000706! Article 3" Objective:" To understand how UFEPs influence health care seeking practices in sub-Saharan Africa.! Methods:" Realist review based on literature published in French or English up to August 2013 on UFEPs in sub-Saharan Africa.! Analysis:" Theory-based analysis using a Context- Mechanism-Outcome (CMO) framework combining the Health Access Framework (Obrist et al., 2005) and the ʻempowermentʼ theory.! Service provision Health personnel Health information Drugs and vaccines Funding Governance and leadership Increase in service utilization Increase of workload Insufficient medical staff Loss of income Lack of time for consultations Feeling of being exploited, overworked Negative attitude of medical staff Deterioration of staff morale No information on: - number and type of services provided - amount of reimbursements Shortages of drugs and kits Delays and under- distribution of consumables Unpredictable, insufficient and discontinuous funding Loss of income and increased debts for health centres Reverting back to charging for services and drugs Difficulty to pay recurrent expenses Poor planning and communication Poor understanding of policies Inadequate supervision ‘No blame game’ Results:" • 140 documents from 56 GHAs included.! • Stances of GHAs presented in Table 1.! • Arguments to justify stance: economic, moral and ethical, and pragmatic.! Discussion:" • Consensus, at least from a rhetorical point of view, in favor of avoiding user fees.! • Possible drivers of change in stance: scientific knowledge, networks of actors, and LMICs.! • Words not systematically turned into deeds.! Source: Robert, E., & Ridde, V. (2013). Global health actors no longer in favor of user fees: a documentary study. Globalization and health 9: 29. doi:10.1186/1744-8603-9-29! Results:" • 23 articles from 7 countries (Ghana, Kenya, Madagascar, Senegal, South Africa, Tanzania and Uganda) included.! • Pressures synthesized in Table 2.! Discussion:" • Risk of negative effects of UFEPs because of bottlenecks.! • Need for more empirical studies aimed at understanding more clearly how UFEPs affect, at one and same time, all the functions of the health system.! Source: Ridde, V., Robert, E., & al. (2012). A literature review of the disruptive effects of user fee exemption policies on health systems. BMC Public Health 12: 289. doi: 10.1186/1471-2458-12-289! Empowerment of beneficiaries (M)" AFFORDABILITY (C)" User fee exemption policy" ACCESSIBILITY (C)! AVAILABILITY (C)! ADEQUACY (C)! ACCEPTABILITY (C)! Beneficiaries seek free health care (O)." ʻEmpowering situationʼ# HEALTHCARESERVICES(C)! NORMS, POLICIES, INSTITUTIONS, AND PROCESSES (C)! LIVELIHOODASSETS(C)! VULNERABILITY CONTEXT (C)! Preliminary results:" • Results of theory-building process presented in Figure 2.! • 118 documents from 12 African countries selected, and 66 included for theory- testing.! • Preliminary CMO configurations in Box 1. ! Discussion:" • Economic, social and geographic vulnerability, and resulting livelihood assets, influence the degree of empowerment that UFEPʼs target populations have to seek free health care.! Source: Robert, E., & Ridde, V. (2013). Lʼapproche réaliste pour lʼévaluation de programmes et la revue systématique: de la théorie à la pratique. Mesure et évaluation en éducation. 36(3):79-108.! Configuration 1: Availability of physical capital, such as proximity of health facilities, availability of transport, and quality of road infrastructures (C), empowers the target populations of the UFEP to seek free health care (M). Use of free health care is thus favored (E).! Configuration 2: In contrast, contexts of geographical vulnerability (C) undermine the empowerment of the UFEPʼs target populations (M) and contribute to the renunciation of free health care or to the use of other health providers (E).! Configuration 3: UFEPs target populations facing financial hardship cannot afford the indirect costs associated with accessing free health care (C), and this undermines their empowerment to seek free health care (M). As a consequence, they may renounce free health care, or chose other health providers (E).! Configuration 4: Benefitting from social capital within the community or within health facilities creates a context in which free health care is more accessible (whether financially, culturally or geographically) to the UFEPʼs target populations (C), which strengthens their empowerment (M). As a consequence, they are more likely to seek free health care (E). ! Configuration 5: Conversely, the absence of social capital (C) undermines the empowerment of the UFEPs target populations (M), discouraging them from seeking free health care (E).! Health care seeking practices" Global governance ! Stance of Global Health Actors on user fees" ECONOMIC,SOCIAL-CULTURAL,AND ENVIRONMENTALDETERMINANTS! INSTITUTIONALDETERMINANTS! Health policy! User fee exemption policies" Health system and services! Disruptive effects of user fee exemption policies"