The lack of free access to health services and the impact on implementation: the user fees and their impact

2

Why were user fees introduced?

Argument 1: user fees improve efficiency• Reduce unnecessary demand• Reduce inappropriate use of referrals• Encourage people to take better care of themselves• Increases ownership of health servicesIn practice…• Patients are not doctors• Free care at the point of delivery does not mean that to

seek care is free• User fees will not reduce the demand of the richest patients• In most places, users are not empowered “customers”.

3

Why were user fees introduced?

Argument 2. user fees raise financial resources

• shifts part of the costs to the patient and frees public funds

• user charges will raise additional revenues

• brought new funding for health facility level

In practice…

• The revenue raising potential of user fees has been very low, about 5% of healthcare expenditure

• assumption that utilization by patients will not fall

4

Why were user fees introduced?

Argument 3: A cost recovery system improves the equity of the health system

• User fees could eliminate inequity by raising revenue to improve quality and coverage for the poor

• Frees government resources to be allocated towards the poorest

• Exemption systems

In practice…

• Exemption systems do not work

• Excludes the poor from healthcare

• Revenue rarely kept at local level

5

• Elimination of user fees could prevent Elimination of user fees could prevent approximately 233,000 (estimate range approximately 233,000 (estimate range 153,000-305,000) deaths annually in children 153,000-305,000) deaths annually in children aged under 5 in 20 African countries.aged under 5 in 20 African countries. (BMJ (BMJ 2005)2005)

• Immediate and increased utilisation rate for Immediate and increased utilisation rate for maternal and child health servicesmaternal and child health services

• Ends the situation that user fees are not a Ends the situation that user fees are not a source of income, they are a form of rationing, source of income, they are a form of rationing, based on wealthbased on wealth

• People should pay for healthcare according to People should pay for healthcare according to their ability, but receive health care according their ability, but receive health care according to need.to need.

Benefits

Change in Outpatient attendances Q2 2005 to Q2 2006 Southern Province Zambia

0%

10%

20%

30%

40%

50%

60%

70%

80%

Rural Districts:Fees Abolished

Urban Districts:Fees Retained

Increases in Hospital Services in Burundi 3 months After Fees Were Abolished for Maternity and Children's Services

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Child outpatients Deliveries Caesarean sections

8

Attaining the health MDGs- the importance of consuming services child mortality rate vs total outpatient utilisation in selected countries

0

50

100

150

200

250

300

0 0.2 0.4 0.6 0.8 1 1.2 1.4

Outpatient visits per person per year

Child

mor

talit

y ra

te (p

er 1

000

live

birth

s) DRCRwanda

Zambia

Mozambique

Burkina Faso

Malawi

Uganda

Somalia

Tanzania

Sudan

South Sudan

Botswana

9

The Sudden and Sustained Impact of Abolishing User Fees Total Monthly Outpatient Attendances in Kisoro District 1998-2007

0

10000

20000

30000

40000

50000

60000

Jan98

Jan99

Jan00

Jan01

Jan02

Jan03

Jan04

Jan05

Jan06

Jan07

Outpatient attendances 12 month moving average

User fees abolished

200% increase

Utilisation Rate1.6 visits perperson per year

10

Emerging ConsensusEmerging Consensus

• UK Government led the Taskforce on Innovative UK Government led the Taskforce on Innovative Financing and 23 September 2009 eventFinancing and 23 September 2009 event

• Global Consensus on MNCH supports removal of fees Global Consensus on MNCH supports removal of fees “where countries choose”“where countries choose”

• Consensus warmly welcomed by the G8 2009 L’Aquila Consensus warmly welcomed by the G8 2009 L’Aquila including removal of fees “where countries choose”including removal of fees “where countries choose”

• World Bank HNP Strategy 2007: “Upon client-country World Bank HNP Strategy 2007: “Upon client-country demand, the Bank stands ready to support countries demand, the Bank stands ready to support countries that want to remove user fees from public facilities that want to remove user fees from public facilities ifif……..” with multiple reservations……..” with multiple reservations

• Margaret Chan: Margaret Chan: “please let’s work together to support “please let’s work together to support countries to implement ways to get rid of all these countries to implement ways to get rid of all these barriers and most important of all user feesbarriers and most important of all user fees.”.”

• EC Council Conclusions 2010EC Council Conclusions 2010

11

Senegal free deliveries 2006

Liberia all services free Feb 2007

Niger free for <5s and deliveries 2006

Kenya free deliveries Oct 07

Sudan free services for <5s and c-sections Feb 2008

Uganda all services free Mar 01

Burundi free for <5s and deliveries Aug 06

Zambia free services in rural districts Apr 06

The Rapid Removal of Health User Fees in Africa since 2000

Lesotho free services at primary level Jan 08

Countries introducing free services since 2000

Countries with free services pre 2000

Ghana free services for children and pregnant women May 08

12

Arguments made in Sierra Arguments made in Sierra LeoneLeone

• Focus on MDGs 4 and 5Focus on MDGs 4 and 5• A proven quick-win in terms of improving A proven quick-win in terms of improving

access access • Strong efficiency and equity argumentsStrong efficiency and equity arguments• Allows space for other public and private Allows space for other public and private

mechanismsmechanisms• Can be achieved only for under 5s and Can be achieved only for under 5s and

pregnant and lactating womenpregnant and lactating women• Countries can define their own package of Countries can define their own package of

servicesservices• Consistent with universal coverage and Consistent with universal coverage and

rightsrights• Many LICs are doing this anyway – not Many LICs are doing this anyway – not

donor-leddonor-led

13

Preparation for 27 April Preparation for 27 April 20102010

• analyze country situationanalyze country situation• set up of steering group and 6 sub set up of steering group and 6 sub

committees in areas of HR, Logistics & committees in areas of HR, Logistics & drugs, communications, M&E, finance & drugs, communications, M&E, finance & governance and infrastructuregovernance and infrastructure

• weekly sub-committee update on weekly sub-committee update on progressprogress

• Save the children co-chaired the Save the children co-chaired the communications sub committeecommunications sub committee

• launch on independence day (April 27)launch on independence day (April 27)

14

Success:Crowd waiting at the PCM Hospital

15

Success; beneficiaries waiting for Success; beneficiaries waiting for services at Goderich community services at Goderich community health centrehealth centre

Thank you for listening

Amie Lompri KoromaAmie Lompri Koroma

Health Programme OfficerHealth Programme Officer

Save the Children, Sierra LeoneSave the Children, Sierra Leone