Implementing funding modalities for free access: The case for a "purchasing fund system" to cover medical care

The principle of free access to ARVs was recognized in Senegal in 2003. Debate now focuses on its expansion to cover all therapeutic care (consultations, exams, treatment for opportunistic infections). Expenditures incurred by this complementary packet often impede access to care. The main difficulty does not really arise from the need for funding but rather from how this treatment is managed and its impact on the current financing systems. In fact, four types of possible funding exist: (1) provision in kind of products necessary for the consumption of free services; (2) providing equipment that allows other revenues in compensation for losses created by free access; (3) increased public budgetary grants; (4) reimbursement for services by a third party. In this last solution, the third party may be the State or an ad hoc organism (NGO, insurance, designated fund). The study compares these different modalities across specific conditions in Senegal and describes their possible impact on the present and future health system. In effect, this analysis fits into a much broader debate since the principle of free access has already expanded to other domains, particularly childbirth (2003) and care for the elderly (2006). The study shows that the multiplication of parallel supplies, the coexistence of various “free” stocks and insufficient accounting of services might create serious disturbances in current management and financing systems. On the other hand, invoice reimbursements set up in some districts by various partners preserve financial autonomy and strengthen the managerial capacities of health structures. Nevertheless, with the increased number of people who are treated and the expansion of free access to other services, there is a risk of letting the number of individual mechanisms multiply when common services would be more effective. Given the financial limitations of community financing schemes and the difficulties to develop insurance systems in a very informal economy, it is now necessary to envisage the implementation of “purchasing funds,” for which the study proposes basic guidelines. Based on the logic of insurance, they rely on purchasing a predetermined service package (contractualization and accreditation), using the sectoral approach (by “pooling” public, private and international resources), funding based on results (a payment for services rendered) and management that is independent of public budgetary blockages (with the participation of civil society). Complete medical treatment for PLWHA may be the best way to progressively start this process because the service package is clearly predetermined, its cost has been assessed and the number of beneficiaries, in a country like Senegal, is still low. Moreover, if proper management of this fund can be ensured, institutional sustainability will ensure its financial sustainability. Therefore the fight against HIV/AIDS could contribute to reflection on health system reform.VIH ; sida ; accès aux soins ; financement de la santé ; fonds d'achat ; gratuité ; Sénégal

The cost of universal free access for treating HIV/AIDS in low-income countries: the case of Senegal

Since late 2003 in Senegal, voluntary tests, ARVs and CD4 counts have been provided free of charge by the State within the framework of public health services. Debate now focuses on expanding free access to other components of care (consultations, hospitalizations, complementary exams for opportunistic infections). A preliminary study assessed the supplementary cost needed to fund all care and appraised this measure's impact on the national program. Direct costs for treatment were calculated using two different methods: (1) by calculating total expenditures for a sample of 299 patients over a 22-month period (July 2003 to April 2005) treated by HAART (2 NRTI + 1 PI or NNRTI); and (2) by assessing the theoretical costs necessary to apply the national treatment protocols. Furthermore, national budgetary projections were analyzed to estimate possible margins available to officials. In 2006, the total cost of medical care for someone taking ARVs falls around 412€ per year; 84% of the cost covers the price of ARVs and reagents for CD4 counts. The total annual cost of medical care for a PLWHA who does not need ARV drugs is approximately 40€ per year, with 90% of this amount covering biological exams. Projections concerning changes in the number of PLWHA and treatment needs and analysis of budget estimations for 2007-2011 demonstrate that supplementary costs incurred by complete free access could be easily covered without disrupting the proposed funding plan. Complete free access for medical care for all PLWHA in the country is therefore economically feasible; what remains is to define this decision's integration into the current paying health system without causing disturbances that render the decision ineffective.VIH ; sida ; mdicaments antirétroviraux ; prise en charge médicale ; accès aux soins ; financement de la santé ; gratuité ; payement par les usagers ; Sénégal

The cost of universal free access for treating HIV/AIDS in low-income countries: the case of Senegal

Since late 2003 in Senegal, voluntary tests, ARVs and CD4 counts have been provided free of charge by the State within the framework of public health services. Debate now focuses on expanding free access to other components of care (consultations, hospitalizations, complementary exams for opportunistic infections). A preliminary study assessed the supplementary cost needed to fund all care and appraised this measure's impact on the national program. Direct costs for treatment were calculated using two different methods: (1) by calculating total expenditures for a sample of 299 patients over a 22-month period (July 2003 to April 2005) treated by HAART (2 NRTI + 1 PI or NNRTI); and (2) by assessing the theoretical costs necessary to apply the national treatment protocols. Furthermore, national budgetary projections were analyzed to estimate possible margins available to officials. In 2006, the total cost of medical care for someone taking ARVs falls around 412€ per year; 84% of the cost covers the price of ARVs and reagents for CD4 counts. The total annual cost of medical care for a PLWHA who does not need ARV drugs is approximately 40€ per year, with 90% of this amount covering biological exams. Projections concerning changes in the number of PLWHA and treatment needs and analysis of budget estimations for 2007-2011 demonstrate that supplementary costs incurred by complete free access could be easily covered without disrupting the proposed funding plan. Complete free access for medical care for all PLWHA in the country is therefore economically feasible; what remains is to define this decision's integration into the current paying health system without causing disturbances that render the decision ineffective

Implementing funding modalities for free access: The case for a "purchasing fund system" to cover medical care

The principle of free access to ARVs was recognized in Senegal in 2003. Debate now focuses on its expansion to cover all therapeutic care (consultations, exams, treatment for opportunistic infections). Expenditures incurred by this complementary packet often impede access to care. The main difficulty does not really arise from the need for funding but rather from how this treatment is managed and its impact on the current financing systems. In fact, four types of possible funding exist: (1) provision in kind of products necessary for the consumption of free services; (2) providing equipment that allows other revenues in compensation for losses created by free access; (3) increased public budgetary grants; (4) reimbursement for services by a third party. In this last solution, the third party may be the State or an ad hoc organism (NGO, insurance, designated fund). The study compares these different modalities across specific conditions in Senegal and describes their possible impact on the present and future health system. In effect, this analysis fits into a much broader debate since the principle of free access has already expanded to other domains, particularly childbirth (2003) and care for the elderly (2006). The study shows that the multiplication of parallel supplies, the coexistence of various “free” stocks and insufficient accounting of services might create serious disturbances in current management and financing systems. On the other hand, invoice reimbursements set up in some districts by various partners preserve financial autonomy and strengthen the managerial capacities of health structures. Nevertheless, with the increased number of people who are treated and the expansion of free access to other services, there is a risk of letting the number of individual mechanisms multiply when common services would be more effective. Given the financial limitations of community financing schemes and the difficulties to develop insurance systems in a very informal economy, it is now necessary to envisage the implementation of “purchasing funds,” for which the study proposes basic guidelines. Based on the logic of insurance, they rely on purchasing a predetermined service package (contractualization and accreditation), using the sectoral approach (by “pooling” public, private and international resources), funding based on results (a payment for services rendered) and management that is independent of public budgetary blockages (with the participation of civil society). Complete medical treatment for PLWHA may be the best way to progressively start this process because the service package is clearly predetermined, its cost has been assessed and the number of beneficiaries, in a country like Senegal, is still low. Moreover, if proper management of this fund can be ensured, institutional sustainability will ensure its financial sustainability. Therefore the fight against HIV/AIDS could contribute to reflection on health system reform

Chapitre 6. Quelles sont les conséquences économiques du trachome et quel est l’impact économique des interventions dans ce domaine ? La réduction du trachome peut-elle être utilisée comme un indicateur de développement dans les zones d’endémie ?

Le lien entre trachome et pauvreté a été souvent mis en valeur et il n’est donc pas étonnant que la réduction du trachome soit apparue comme un indicateur commode du développement. Le coût d’une enquête de prévalence sur un échantillon représentatif est modeste et peut se faire relativement rapidement. Ces enquêtes n’exigent pas un personnel très qualifié car le diagnostic peut être opéré de manière relativement fiable après une formation courte. Il est aussi particulièrement rentable d’utili..

Les stratégies sur le marché mondial des médicaments contre le SIDA

Face à une situation de marché très mouvante où le contexte politique est primordial, nous proposons une analyse en trois temps : en premier, une esquisse de la chronologie des événements, en second lieu, l'identification de la position des différents types d'acteurs et en troisième lieu sont proposés trois scénarios qui sont à la fois des interprétations simplifiées du jeu des acteurs et des perspectives sur les évolutions possibles

World market strategies for drugs to fight AIDS

Faced with a situation where the market is unstable and the political context is crucial, we propose a three-part analysis. In the first part, an overview of the chronology of the main events shows that the evolution of the price of ARVs is interlinked with numerous issues of pharmaceutical patent rights. In the second part, we analyse the positions of stakeholders : how they behave in the market and influence market regulations. In the third part, we propose three scenarios which are both simplified interpretations of stakeholders' strategies and options for the future. The first scenario is the status quo, where prices are high. The second scenario is driven by multinational companies who work to enlarge the markets by price differentiation and product diversification. The third scenario is driven by International Organisations which achieve a political consensus to enlarge access to ARV drugs through broader international financing and a systematic opening of the market to generics.Face à une situation de marché instable où le contexte politique est primordial, nous proposons une analyse en trois parties. Dans la première partie une esquisse de la chronologie des événements montre que l'évolution des prix des ARV est liée dans le temps à de nombreux débats sur les brevets des médicaments. Dans la seconde partie, nous analysons les positions des parties intéressées : comment elles agissent sur le marché et sur la réglementation du marché. Dans la troisième partie, sont proposés trois scénarios qui sont à la fois des interprétations simplifiées du jeu des acteurs et des perspectives sur les évolutions possibles. Le premier scénario est celui du statut quo ante, les prix restent élevés. Le second scénario est conduit par les firmes multinationales qui jouent l'extension du marché par différentiation des prix et diversification des produits. Le troisième scénario est conduit par les organisations internationales qui réalisent un consensus politique pour élargir l'accès aux ARV : par un large financement et/ou par l'ouverture systématique aux génériques

Lutte contre le trachome en Afrique subsaharienne

Le trachome, la maladie des « cils qui poussent à l’intérieur », est la deuxième cause de cécité dans le monde. Bien qu’elle soit susceptible d’être prévenue et traitée, elle frappe encore près de 80 millions de personnes, en particulier dans le sud du Sahara. Quelles sont les causes de cette maladie ? Comment y faire face ? Comment évaluer le succès des actions préventives ou curatives déjà entreprises ? Où en est la lutte contre cette infection et quelles sont les recommandations nécessaires à son éradication ? Cette expertise collégiale menée par l’IRD, réalisée par une quinzaine de chercheurs à la demande du ministère de la Santé du Mali et de l’Institut d’ophtalmologie tropicale d’Afrique (Mali), s’attache à décrire l’état actuel de la lutte contre cette conjonctivite cécitante d’origine infectieuse. En dressant le bilan des stratégies déjà à l’œuvre, notamment celle du programme CHANCE de l’OMS, cette expertise cherche à définir les conditions et les perspectives de cette maladie.Trachoma, the disease of the “eyelashes which turn inward”, is the second cause of blindness in the world. Although it can be predicted and treated, it still affects nearly 80 million people, particularly in the South Sahara. What are the causes of this disease? How can it be combated? How can the success of preventative and curative actions already undertaken be evaluated? What is the current situation in the fight against this infection and what lessons can be drawn? This IRD Expert Group Review, conducted by more than a dozen researchers at the request of the Malian Health Ministry and the Institut d’ophtalmologie tropicale de l’Afrique in Bamako, describes the current situation in the fight against this blinding conjunctivitis of infectious origin. By evaluating the strategies already deployed – particularly the WHO SAFE strategy – it seeks to define the conditions and prospects for its eradication