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.

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. Outline
• Context
• Objectives
• Methodology
• The framework
• Results
• Main Lessons
• Conclusion

3. Context
• Bamako Initiative 1987
• Structural adjustments
• Scientific debate
• Out of Pocket Payment’s negative impact

4. Context (2)
Yates 2009 doi:10.1016/S0140-6736(09)60258-0

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. 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. 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. Results

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. 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. Actors
• Strong national ownership of the decision
• International actors setting the scene but absent
during remainder of process
• Implementers are not involved

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. 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. Process
• Perceived as a “Quick Win” strategy
• Technical issues underestimated
• Abolition of user fees and output-based
financing ?
• Monitoring and Evaluation is crucial

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. 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. 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