Removing User Fees In SSA D Hercot

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Short presentation of a review of the policy process of the removal of user fees in the health sector in six Sub Saharan Africa countries.

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Removing User Fees In SSA D Hercot

  1. 1. Removing User fees Review of the policy process in six sub-Saharan African countries Bruno Meessen, David Hercot, Mathieu Noirhomme, Valery Ridde, Abdelmajid Tibouti, Abel Bicaba, Christine Kirunga Tashobya and Lucy Gilson
  2. 2. Outline • Context • Objectives • Methodology • The framework • Results • Main Lessons • Conclusion
  3. 3. Context • Bamako Initiative 1987 • Structural adjustments • Scientific debate • Out of Pocket Payment’s negative impact
  4. 4. Context (2) Yates 2009 doi:10.1016/S0140-6736(09)60258-0
  5. 5. Objectives • To draw lessons that could guide the future formulation and implementation of ‘user fees abolition’ policies in other countries. This review is not : • an advocacy tool (user fee abolition is right or wrong) • a scientific research.
  6. 6. Methodology • Six countries in Sub-Saharan Africa. • Development of an analytical framework building on Walt & Gilson Health Policy Analysis Triangle • To describe the process of policy reform • Field visits and literature review • Data analysis and synthesis exercise • Production of a report and guidance note
  7. 7. Framework AGENDA CONTEXT ACTORS ARENA CONTENT Elected officials Global Appointed Individual FORMULATION officials citizens Members of National Interest groups IMPLEMENTATION Strategic Groups Health Sector Entrepreneurs EFFECT Walt and Gilson (1994), Olivier de Sardan (1995), Kingdon (1995), Gilson et al. (2000), Lemieux (2002)
  8. 8. Results
  9. 9. Content of the reform in the six countries 3/2005, 1/2006 ; 1/2007 ; Deliveries, C- 3/2001 ; Universal Deliveries (HC), C- sections and neonates, in public facilities section (hosp) [but 80% subsidy Dakar] 5/2006 ; 4/2006 ; Universal 9/2003, 4/2005 ; Deliveries and Deliveries under 5 Yates 2009 doi:10.1016/S0140-6736(09)60258-0
  10. 10. Context, Content • Abolition of user fees happens; environment is favourable • Content is context specific • Focus on children and pregnant women • Accompanying measures are inadequate
  11. 11. Actors • Strong national ownership of the decision • International actors setting the scene but absent during remainder of process • Implementers are not involved
  12. 12. Formulation Burki Buru Liberi Ugan Ghan Seneg na ndi a da a al Preliminary situation analysis Yes No No Yes No +/- International and National Scientific +/- No No No Yes evidence Clarity of the policy objectives Yes +/- +/- Yes Yes Yes Considering different policy options Yes No Yes Yes No No Thorough assessment of the option Yes[1] No No No No No Early identification of accompanying No No No Yes No No measures Vision, ownership and leadership Yes +/- Yes Yes +/- +/- Involving in the formulation stage +/- No No No No No stakeholders crucial for the implementation The content of the reform meets Yes Yes Yes +/- Yes Yes preferences of stakeholders
  13. 13. Implementation Burki Burun Liberi Ugan Ghan Seneg na di a da a al Sequencing of the reform No No + No + + Planning process + No + + No + Communication strategies – Stakeholders ++ No No + + + (not users) Communication strategies – Users + + + ++ + + Medium term commitment on budgetary ++ + ++ ++ No No burden Channelling of resources Same New Adapt Same New New Leadership by the government ++ + ++ +++ + + Capacity building + No No No No No Empowered coordination unit + + ++ ++ No + M&E of the reform + + + +++ No No
  14. 14. Process • Perceived as a “Quick Win” strategy • Technical issues underestimated • Abolition of user fees and output-based financing ? • Monitoring and Evaluation is crucial
  15. 15. Effects • Clear increase in utilisation in the short term. • Higher increase in utilisation for poorer households in Uganda and Ghana • Mainly generating satisfaction among population • No evidence of impact on child and maternal mortality • No evidence on financial protection
  16. 16. Main Lessons • Technical dimension is often under-estimated. • Increase resources at local level • Other barriers should be tackled • International partners should be more supportive
  17. 17. Conclusions • User fee removal is a means, not an aim • When you go for it, do it right Thank You http://www.itg.be/unicef David Hercot Be Cause Health Nov 26 2009

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