Fee Exemption for Maternal Care in Sub-Saharan Africa: A Review of 11 Countries and Lessons for the Region

Several countries have recently introduced maternal health care fee exemptions as a quick win approach to reach MDG 5 goals. It has also been argued that these policies were relevant first steps towards universal health coverage (UHC). The scope and contents of the benefits package covered by these policies vary widely. First evaluations raised questions about efficiency and equity. This article offers a more comprehensive view of these maternal health fee exemptions in Africa. We document the contents and the financing of 11 of these policies. Our analysis highlights (1) the importance of balancing different risks when a service is the target of the policy - C-sections address some of the main catastrophic costs, but do not necessarily address the main health risks to women, and (2) the necessity of embedding such exemptions in a national framework to avoid further health financing fragmentation and to reach UHC.sch_iih6pub3250pub

Challenges of scaling up and of knowledge transfer in an action research project in Burkina Faso to exempt the worst-off from health care user fees

<p>Abstract</p> <p>Background</p> <p>Systems to exempt the indigent from user fees have been put in place to prevent the worst-off from being excluded from health care services for lack of funds. Yet the implementation of these mechanisms is as rare as the operational research on this topic. This article analyzes an action research project aimed at finding an appropriate solution to make health care accessible to the indigent in a rural district of Burkina Faso.</p> <p>Research</p> <p>This action research project was initiated in 2007 to study the feasibility and effectiveness of a community-based, participative and financially sustainable process for exempting the indigent from user fees. A interdisciplinary team of researchers from Burkina Faso and Canada was mobilized to document this action research project.</p> <p>Results and knowledge sharing</p> <p>The action process was very well received. Indigent selection was effective and strengthened local solidarity, but coverage was reduced by the lack of local financial resources. Furthermore, the indigent have many other needs that cannot be addressed by exemption from user fees. Several knowledge transfer strategies were implemented to share research findings with residents and with local and national decision-makers.</p> <p>Partnership achievements and difficulties</p> <p>Using a mixed and interdisciplinary research approach was critical to grasping the complexity of this community-based process. The adoption of the process and the partnership with local decision-makers were very effective. Therefore, at the instigation of an NGO, four other districts in Burkina Faso and Niger reproduced this experiment. However, national decision-makers showed no interest in this action and still seem unconcerned about finding solutions that promote access to health care for the indigent.</p> <p>Lessons learned</p> <p>The lessons learned with regard to knowledge transfer and partnerships between researchers and associated decision-makers are: i) involve potential users of the research results from the research planning stage; ii) establish an ongoing partnership between researchers and users; iii) ensure that users can participate in certain research activities; iv) use a variety of strategies to disseminate results; and v) involve users in dissemination activities.</p

Assessing Communities of Practice in health policy : A conceptual framework as a first step towards empirical research

Peer reviewe

Low coverage but few inclusion errors in Burkina Faso: a community-based targeting approach to exempt the indigent from user fees

<p>Abstract</p> <p>Background</p> <p>User fees were generalized in Burkina Faso in the 1990 s. At the time of their implementation, it was envisioned that measures would be instituted to exempt the poor from paying these fees. However, in practice, the identification of indigents is ineffective, and so they do not have access to care. Thus, a community-based process for selecting indigents for user fees exemption was tested in a district. In each of the 124 villages in the catchment areas of ten health centres, village committees proposed lists of indigents that were then validated by the health centres' management committees. The objective of this study is to evaluate the effectiveness of this community-based selection.</p> <p>Methods</p> <p>An indigent-selection process is judged effective if it minimizes inclusion biases and exclusion biases. The study compares the levels of poverty and of vulnerability of indigents selected by the management committees (n = 184) with: 1) indigents selected in the villages but not retained by these committees (n = 48); ii) indigents selected by the health centre nurses (n = 82); and iii) a sample of the rural population (n = 5,900).</p> <p>Results</p> <p>The households in which the three groups of indigents lived appeared to be more vulnerable and poorer than the reference rural households. Indigents selected by the management committees and the nurses were very comparable in terms of levels of vulnerability, but the former were more vulnerable socially. The majority of indigents proposed by the village committees who lived in extremely poor households were retained by the management committees. Only 0.36% of the population living below the poverty threshold and less than 1% of the extremely poor population were selected.</p> <p>Conclusions</p> <p>The community-based process minimized inclusion biases, as the people selected were poorer and more vulnerable than the rest of the population. However, there were significant exclusion biases; the selection was very restrictive because the exemption had to be endogenously funded.</p

Ressources financières des comités de gestion du Burkina Faso peuvent améliorer l'équité d'accès au système de santé

Avec l’avènement du système de recouvrement des couts dans les années 1990 au Burkina Faso, les patients contribuent au financement des centres de santé (CSPS) gérés par les comités de gestion (COGES). Mais en demandant aux patients de payer, une barrière financière s’impose aux plus pauvres. L’objectif de cet article est d’étudier la manière dont les ressources financières tirées du recouvrement des couts peuvent contribuer à améliorer l’équité d’accès aux soins de santé. L’étude se déroule dans le district sanitaire de Ouargaye. La méthodologie consiste à documenter la situation financière de 17 COGES sur une période de 12 mois au moyen des données comptables. Les résultats montrent que les COGES ont dépensé en moyenne sept millions de francs CFA (FCFA), dont 65 % pour l’achat des médicaments, 15 % pour les frais de fonctionnement, 7 % pour le salaire du personnel et les primes aux COGES et 3,4 % pour les ristournes aux agents de santé. Les recettes moyennes par COGES sont de 7,3 millions de FCFA. La vente des médicaments essentiels génériques correspond à 82 % des recettes, et la tarification des actes a` 10 %. Le résultat comptable moyen annuel est de 300 000 FCFA. Le taux de recouvrement des dépenses est de 104 % en moyenne. La marge bénéficiaire sur la vente des médicaments est de 31 % en moyenne. Les ristournes aux agents de santé correspondent à 30 % des recettes de la tarification des actes en moyenne. La trésorerie moyenne est de 3,1 millions de FCFA. Les COGES disposent d’une bonne capacité financière. Ils pourraient améliorer l’accès aux soins en respectant les normes des ristournes aux agents (20 %), en supprimant la tarification des actes, en réduisant les marges sur la vente des médicaments ou en utilisant une partie des bénéfices pour exonérer du paiement les plus pauvres

Enjeux disciplinaires, éthiques et politiques d'une recherche-action sur l'accès aux soins de santé des indigents au Burkina Faso

International audienc

Maternal health fee exemptions : policy brief

Sixty participants from 10 countries including four English-speaking (Ghana, Kenya, Nigeria, Sierra Leone) and six French-speaking (Benin, Burkina Faso, Mali, Morocco, Niger, Senegal) attended the workshop, which presented data from the ten countries as the basis for discussion and comparison of content, costs and financing of maternal health fee exemption policies. Countries also identified priority activities to implement to improve their maternal health fee exemption policies upon their return home. There is a lack of coordination both among different fee exemption policies in place (children under five, pregnant women, etc.) and other major initiatives designed to improve financial access

Targeting the worst-off for free health care : a process evaluation in Burkina Faso

Effective mechanisms to exempt the indigent from user fees at health care facilities are rare in Africa. A State-led intervention (2004–2005) and two action research projects (2007–2010) were implemented in a health district in Burkina Faso to exempt the indigent from user fees. This article presents the results of the process evaluation of these three interventions. Individual and group interviews were organized with the key stakeholders (health staff, community members) to document the strengths and weaknesses of key components of the interventions (relevance and uptake of the intervention, worst-off selection and information, financial arrangements). Data was subjected to content analysis and thematic analysis. The results show that all three intervention processes can be improved. Community-based targeting was better accepted by the stakeholders than was the State-led intervention. The strengths of the community-based approach were in clearly defining the selection criteria, informing the waiver beneficiaries, using a participative process and using endogenous funding. A weakness was that using endogenous funding led to restrictive selection by the community. The community-based approach appears to be the most effective, but it needs to be improved and retested to generate more knowledge before scaling up