SD/ WA 09

Satellite document
Wide angle Collection
Understanding financial access to physical
and functional rehabilitation services in
developing countries
Technical Resources Division
July 2014
SD/ WA 09
Authors
Alain LETOURMY, economist, honorary researcher at the CNRS
Review committee
Clément BAGNOA
Grégory DOUCET
Emmanuelle DUCASSE
Augustin NEOUZE
Isabelle URSEAU
Validation committee
Rozenn BOTOKRO BEGUIN
A Handicap International publication
Knowledge Management Unit
Technical Resources Division
Editor, layout
Stéphanie DEYGAS
Knowledge Management Unit
Photo Credit
© Bernard Franck / Handicap International (Cambodia, 2004)
This document may be used or reproduced only if the source is cited and only for noncommercial purpose.
1
Contents
Acronyms ................................................................................................................................................ 4
Summary ................................................................................................................................................. 6
Introduction .......................................................................................................................................... 8
The problem posed by Handicap International .............................................................................. 8
Methods .................................................................................................................................................. 8
Analysis of the economic system for physical and functional rehabilitation ................ 10
1. General considerations on physical and functional rehabilitation ............................... 10
1.1 Defining the economic system for physical and functional rehabilitation and the acts
considered in the study................................................................................................................. 10
1.2 Sources of physical and functional rehabilitation needs................................................... 11
1.3 The upstream and downstream of physical and functional rehabilitation ...................12
2. The supply of physical and functional rehabilitation services in developing
countries .............................................................................................................................................. 13
2.1 Ideal integrated supply and incomplete supply .................................................................. 13
2.2 How access to physical and functional rehabilitation is organised in the public
health care sector ...........................................................................................................................15
2.3 Public supply and private supply ..........................................................................................16
2.4 Financing the supply of physical and functional rehabilitation ..................................... 17
2.5 Human resources .....................................................................................................................19
2.6 Supply for service providers................................................................................................ 20
2.7 Geographical disparities in the physical and functional rehabilitation supply ...........21
2.8 Financing the supply and the need for investment ........................................................ 22
3. The cost to the user ................................................................................................................... 24
3.1 The cost of services and orthopaedic fitting .................................................................... 24
3.2 Other access costs................................................................................................................. 25
3.3 Lost income ............................................................................................................................. 26
3.4 Upstream and downstream costs ....................................................................................... 26
3.5 Cost variability ........................................................................................................................ 26
4. Social health insurance and the cost to the user .............................................................27
4.1 Social health insurance ...........................................................................................................27
2
4.2 Individual payment for physical and functional rehabilitation ..................................... 29
4.3 Are the indigent given preference? ................................................................................... 30
4.4 Specific social security benefits for people with disabilities ........................................32
4.5 Universial coverage and compulsory health insurance ..................................................35
4.6 Mutual health insurance ........................................................................................................37
4.7 Other insurance ...................................................................................................................... 43
4.8 Health care purchasing funds and other prepayment systems .................................. 43
5. Capacity for change in the economic system for physical and functional
rehabilitation..................................................................................................................................... 45
5.1 National disability policy ....................................................................................................... 45
5.2 Public and private players .................................................................................................... 48
5.3 Civil society ............................................................................................................................. 49
5.4 Establishing universal health coverage ..............................................................................51
Conclusion .......................................................................................................................................... 52
References ........................................................................................................................................ 54
3
Acronyms
ABMKAR
Association Burkinabé des Masseurs Kinésithérapeutes et Auxiliaires
de Rééducation [Burkinabe association of physical therapists and
rehabilitation assistants]
ADRK
Association de développement de la région de Kaya [Kaya region
development association] (Burkina Faso)
ANTOB
Association Nationale des Techniciens Orthopédistes du Burkina
[Burkina Faso national association of orthopaedic technicians]
ASMADE
Association
SonguiManégré/Aide
au
développement
endogène
(Burkina Faso)
CARPFO
Caisse Autonome de retraite des fonctionnaires (Burkina Faso)
[Independent civil service retirement fund]
CBR
Community-based rehabilitation
CCSAM
Cadre de concertation des structures d’appui des mutuelles de santé
(Burkina
Faso)
[mutual
health
insurance
support
structure
consultation framework]
CERDI
Centre
International
de
Développement
et
de
Recherche
[International Centre for Development and Research]
CFA franc
West African CFA franc
CHI
Compulsory health insurance
CHU/CHR
University hospital/Regional hospital
CNAOB
Centre national d’appareillage orthopédique du Burkina Faso [Burkina
Faso national orthopaedic fitting centre]
CNSS
Caisse nationale de Sécurité sociale (Burkina Faso) [national social
security fund]
CORAPH
Coordination régionale des associations de personnes handicapées
(Burkina
Faso)
[Regional
coordination
of
disabled
people’s
associations]
CSS
Caisse de Sécurité sociale (Senegal) [national social securityfund]
CVA
Cerebrovascular accident/stroke
DECISIPH
Droit, égalité, citoyenneté, solidarité, inclusion des personnes
handicapées – Social Inclusion and Rights Project in West
Africa, launched by Handicap International
DGSN
Direction générale de la solidarité nationale (Burkina Faso)
[directorate general of national solidarity]
EU
European Union
FEBAH
Fédération burkinabé des associations de personnes handicapées
4
[Burkinabe federation of disabled people’s associations]
FSN
Fonds de solidarité nationale (Burkina Faso) [national solidarity fund]
HIV/AIDS
Human
immunodeficiency
virus/Acquired
immune
deficiency
syndrome
INSD
Institut national des statistiques et de la démographie (Burkina
Faso)[national statistics and demography institute]
IPM
Institution de Prévoyance Maladie (Sénégal)
NGO
Non-governmental organisation
OCADES
Organisation catholique pour le développement et la solidarité
[Catholic organisation for development and solidarity] (connected
with Caritas) (Burkina Faso)
PED
Pays en développement
PNDS
Plan
national
de
développement
sanitaire
[national
health
development plan]
PROS
Programme de renforcement des organisations de la société civile
[Programme to strengthen civil society organisations] (Burkina Faso)
PTF
Technical and financial partners
RAMS
Réseau d’appui aux mutuelles de santé (Burkina Faso) [Support
network for mutual health insurance schemes]
RENOH
Réseau
national
des
organisations
de
personnes
handicapées[national network of disabled people’s organisations]
(Burkina Faso)
REPTO
Rééducation Pour Tous [Rehabilitation for All] (Burkina Faso)
SNV
Dutch NGO
UEMOA
Union économique et monétaire ouest Africaine [West African
Economic and Monetary Union]
UHC
Universal health coverage
UTM
Union technique de la mutualité malienne [Union of Malian mutual
insurance organisations]
VHI
Voluntary health insurance
WHO
World Health Organisation
5
Summary
This document is an overview aimed at providing an understanding of the economics of the
physical and functional rehabilitation system. It is the first part of a study aimed at giving
Handicap International’s teams in the field a tool for diagnosing the economic system for
physical and functional rehabilitation, starting with West Africa. The proposed diagnostic
tool will be the subject of another publication.
The study was done in two stages. First, an analysis of the economic system for physical
and functional rehabilitation was done and this led to an initial draft of a tool. Starting from
that draft, a study done in Burkina Faso then helped to clarify many points and give a
concrete picture of the concepts which would be useful in carrying out the analysis.
This report is devoted to providing an economic analysis of the physical and functional
rehabilitation system.
First we should note that in this report, the physical and functional rehabilitation system
was studied with reference to services defined according to Handicap International’s
definition. We then considered three possible sources of physical and functional
rehabilitation needs: impairments acquired at birth or in early childhood, disease sequelae,
and accidents. As these sources indicate, there are almost always upstream events or care
preceding physical and functional rehabilitation (hospital care), and downstream care, such
as adapting the home or environment. This vision of the system helps us to define what
constitutes an ideal adapted range of services and an incomplete range of services.
When examining how access to physical and functional rehabilitation is organised in
developing countries, we saw that there are gaps in public provision, and that there are
both public and a private physical and functional rehabilitation. There are three potential
sources of funding for providers of physical and functional rehabilitation: out-of-pocket
payments made directly by users; private subsidies; and, public subsidies, in particular used
to pay for staff. But conditions in public and private facilities are very different.
Having competent human resources is crucial for health care facilities that want to offer
physical and functional rehabilitation services. We found that physical and functional
rehabilitation often lacks the qualified personnel it needs to increase its coverage in the
field, and that many physical and functional rehabilitation services are dispensed by poorlyqualified personnel. The gaps in the field of physical and functional rehabilitation services
are, therefore, very often reflected in very striking geographic disparities, and the
financing of services is inadequate to cover the investment needs.
6
The cost to the user includes the cost of services and orthopaedic fitting, unsubsidised
access costs (transportation and accommodation), loss of income, and upstream and
downstream costs. Depending on the location of the services and of each person, the cost
of physical and functional rehabilitation services vary and this is an important factor in
deciding to start or continue treatment.
Social health insurance, whose main purpose is to reduce the cost of health care services
to the user, should be used for physical and functional rehabilitation – especially now that
there is a consensus among development organisations in favour of universal health
coverage. Nevertheless, out-of-pocket payments are still the general rule for physical and
functional rehabilitation.
We examined mechanisms that might reduce the cost to users: specific social security
benefits for people with disabilities; universal health coverage and mandatory health
insurance; mutual health insurance; and other types of insurance, health care purchasing
funds and other prepayment systems. We found that there is still much to be done to
improve financial access to physical and functional rehabilitation. Hence, it is important to
examine the economics of physical and functional rehabilitation’s capacity for change,
which depends on the national disability policy, the role of public and private players, civil
society engagement, and the expected impact of universal health care coverage.
Two important principles can be drawn from this: the first is that efforts made to give
support to users should not neglect investment in the physical and functional rehabilitation
sector; the second is that the mechanisms needed to facilitate financial access to physical
and functional rehabilitation should also be as equitable as possible and, as such, be
defined in a way that takes all the costs to users into account, and not just the fees
charged.
In conclusion a variety of recommendations are put forward regarding the steps that
should follow the study. These concern the maintenance of the tool and also suggest
projects that it might lead to. With this in mind, it is proposed that in many countries, the
most useful model for financing access to physical and functional rehabilitation may be an
independently-managed public fund. Since financing access to physical and functional
rehabilitation alone will not provide the sector with the means to expand, and since the lack
of services provided has a significant impact on access costs, one idea to consider would
be giving such a public fund a two-fold mission: to finance access for individuals, and to
invest in human resources, infrastructure and equipment for physical and functional
rehabilitation.
7
Introduction
The problem raised by Handicap International
Handicap International has been working to improve the situation of people with disabilities
in many developing and emerging nations. Among other actions, Handicap International has
helped set up physical and functional rehabilitation services, primarily in partnership with
the national authorities. The impact of this approach has been limited by problems with
financial access to services, given that nearly all the individuals concerned are required to
pay for the services and materials needed to treat their disability. Handicap International
would like to focus more on the financial accessibility of physical and functional
rehabilitation, and after exploring several avenues in the form of free care initiatives
(health equity funds in Rwanda, Mali and Togo 1), would like an analysis of the conditions and
options for financing physical and functional rehabilitation, in order to reduce the financial
barriers hindering access to services and mobility aids.
Methods
The study was based on the need to describe and analyse the economic system for physical
and functional rehabilitation: what are the financial flows? Which agents are its sources and
beneficiaries? The central concept is the cost to the user; this must be determined as
completely as possible so that it can be covered, at least in part, by appropriate
mechanisms. In as much as the components of the cost to the user depend on the supply of
physical and functional rehabilitation in a given country, a “reasoned” description of that
supply is an essential prerequisite to defining the cost. This means describing the supply in
terms of the impact its nature and organisation have on the financing and the cost charged
to the user, and not in terms of building a health system. In addition to the cost charged to
the user, the description should also consider the various financial coverage mechanisms,
along with all of the context-related factors that can impact the financial flows or change
the economic system for physical and functional rehabilitation.
1
See B. Gerbier and R. Botokro. Improving access to rehabilitation care for the poorest: evaluation
of the 3 equity funds set up by Handicap International in Rwanda, Mali and Togo. Handicap
International, 2009.
8
As the study was primarily theoretical, it did not involve systematically collecting disability
data in the countries concerned – in this case, those of West Africa. While some of those
data were useful, they served more for illustration than as the basis for a comparative
study, which was not an objective of the work undertaken.
The study was done in two stages. Using a first draft of the tool that emerged from the
analysis of the economic system for physical and functional rehabilitation, a mission to
Burkina Faso served to clarify many points and give a practical view of the concepts useful
to the analysis. The observation mission did not presume to be a study of the Burkinabe
physical and functional rehabilitation system, if for no other reason than because it was
done in direct connection with Handicap International, which could be viewed as a source of
bias. It did, however, heavily influence the developments in this report, and using the
Burkinabe situation to directly illustrate the arguments presented seemed necessary.
After some general considerations on physical and functional rehabilitation (Part 1), which
help define the scope of the study, we analyse the system first from the perspective of the
existing supply (Part 2), and then from the perspective of demand and how it is financed
(Parts 3 and 4). Finally, we look at issues of national disability policy and how they relate
tothe possibilityof changing the system and the players who might facilitate such change
(Part 5). The conclusion offers a variety of recommendations on the steps that come after
the study.
9
Analysis of the economic system for physical and functional
rehabilitation
1. General considerations on physical and functional rehabilitation
1.1 Defining the economic system for physical and functional rehabilitation and
the acts considered in the study
By “economic system for physical and functional rehabilitation” we mean the configuration
of financial flows associated with the production and consumption of goods and services
contributing to physical and functional rehabilitation.
Those flows involve a whole series of economic agents: first, providers and patients; then,
those who might be involved in compensating them, such as third party payers; and lastly,
those who, in return for payment, supply the providers the ingredients they need to
perform the acts or even participate in access to care – for example, by providing
transportation. They also involve social players who get no direct compensation for
services, but contribute to their delivery –for example, patient organisations and public
social work services.
With so many agents and players involved we are justified in calling it a physical and
functional rehabilitation “system”, in particular to indicate that there are a number of ways
to increase the flows in order to improve access to services for the individuals concerned.
The range of interventions that can be considered physical and functional rehabilitation
can vary depending on the disabilities and impairments one wants to treat. Here we will use
Handicap International’s definition of physical and functional rehabilitation: “The goal of
physical and functional rehabilitation, a process for people with temporary or long-lasting
impairments and disabilities (and their families), is to restore or compensate for functional
loss to allow optimal functioning in interaction with the environment and to prevent or slow
functional deterioration.” 2
2
Physical and functional rehabilitation, Handicap International, Technical Resources Division, 2013,
p. 30.
10
The scope of Handicap International’s Rehabilitation Services Unit activity is primarily to
“promote actions centred on prevention and physical and functional rehabilitation for
people with physical and/or sensory impairments and disabilities” 3, rather than mental and
intellectual impairments and disabilities. The physical and functional rehabilitation system
studied in this report relates to services meeting this definition.
1.2 Sources of physical and functional rehabilitation needs
It is important to specify the source of physical and functional rehabilitation needs,
because it impacts access to services and, in some cases, how they are paid for. Here we
consider three possible sources of physical and functional rehabilitation needs.
First, some people have impairments acquired at birth or in early childhood, often due to a
genetic problem, possibly congenital, or an incident during childbirth. The problem is
detected fairly early, and leads to medical treatment when identified by a competent
facility. Hence, giving birth outside a medical facility delays identification. Poor families
living far from care may not see a doctor, even when the disability is apparent. In such
cases, family awareness-raising is important for triggering recourse to the medical system
and then, if necessary, access to physical and functional rehabilitation.
Disease sequels are a second source of physical and functional rehabilitation needs.
Consider, for example, childhood polio or meningitis, or stroke in an adult. In this case,
almost everyone passes through the medical system, which in principle results in the
prescription of treatment that includes physical and functional rehabilitation. That
prescription is followed by acts, depending on the physical and financial possibility of
accessing such care.
The third source of need is accidents: domestic accidents, occupational accidents and
traffic accidents. To these we might add trauma suffered in war or natural disasters, which
is also characterised by the fact that – unlike the two preceding sources – they generally
affect previously-healthy people. With most of these events, people go through the
ordinary or humanitarian health care system before any physical and functional
rehabilitation services are considered.
3
Idem, p. 16
11
1.3 The upstream and downstream of physical and functional rehabilitation
As can be seen from the above discussion on the sources of physical and functional
rehabilitation needs, there is almost always an upstream to physical and functional
rehabilitation for individuals involving either voluntary or involuntary hospital care. In most
cases physical and functional rehabilitation comes after trauma surgery (neurosurgery or
orthopaedic surgery), and it is logical that physical and functional rehabilitation services be
articulated with the medical or surgical management that precedes them.
But when it involves making prostheses or orthoses or providing mobility aids, physical and
functional rehabilitation is not the endpoint of an individual’s treatment process. The
person has to be able to move about effectively, both at home and in public places. The
question of adapting the home or environment thus starts a specific process, which may be
personalised or not. From an economic standpoint, that process will take the form of
services, which have a cost and must be financed. Hence there is also a downstream to
physical and functional rehabilitation that it would a logical error to ignore, even though it
means going outside the health care system and mobilising very different players.
12
2. The supply of physical and functional rehabilitation services in
developing countries
2.1 Ideal integrated supply and incomplete supply
In accordance with the preceding elements and the limited scope of the study, in particular,
physical and functional rehabilitation can include three major types of services:
•
diagnostic services, ideally by a physical and functional rehabilitation physician,
surrounded by a team of ancillary professionals;
•
physical, occupational and speech therapy services dispensed by qualified
professionals (physical therapists, occupational therapists and speech therapists);
•
orthopaedic fitting services: orthoses, prostheses, mobility aids and technical aids
dispensed primarily by orthoprosthesists, occupational therapists and physical
therapists.
Physical and functional rehabilitation services often articulate with preceding medical
services, such as orthopaedic surgery. They should be supplemented by an environmental
diagnosis, to render the mobility aids and aids for daily living furnished by the physical and
functional rehabilitation effective or better.
Such an ideal arrangement can be seen in developed countries, and while organised
differently from country to country, it tends to integrate physical and functional
rehabilitation with upstream and downstream services. That integration is not always
perfect, however, and physical and functional rehabilitation, which is follow-up care, may
articulate to a greater or lesser degree with strictly medical care. More generally, the
classic divide between the medical and socio medical sectors complicates the abovementioned process for adapting the environment.
In developing and emerging countries, shortcomings in the supply of physical and
functional rehabilitation are even greater than in developed countries, and the primary
blame lies with the integration of those services. The ideal physical and functional
rehabilitation supply, integrated both upstream and downstream, is extremely rare, and
available only in countries with a high-income segment of the population. These are mostly
emerging countries, where the developed-country system constitutes a (minority) portion
of the health care system, reserved for that fringe of the population. South Africa is an
example of such a two-tiered system.
13
In most developing countries, the supply of physical and functional rehabilitation is more or
less separate from what comes before and after, which obviously complicates the patient
pathway and increases the cost of access. Nevertheless, the ideal supply model can be
used as a reference, and it is useful to look for where it exists in a given country.
The case of Burkina Faso
A full supply of physical and functional rehabilitation exists only in Ouagadougou, provided
one is not too demanding about the downstream side of physical and functional
rehabilitation. In the public sector, the existence of national hospitals and technical
equipment provide the upstream side of physical and functional rehabilitation, which can
itself be dispensed at the CNAOB. T here is no special attention to home adaptation issues,
however. In the private sector, the Paul VI Medical Centre offers surgery, physical therapy
and orthopaedic fitting in a single location. Patient support suggests that there might be
personalised advice on home adaptation at the facility. There are no regular occupational
therapy services as yet, aside from occasional expatriate visits. Two speech therapists
practice independently and with non-profit organisations in Ouagadougou.
Generally speaking, the supply of physical and functional rehabilitation in developing
countries is incomplete, in the sense that in a given area one cannot get all services or go
directly from the hospital to physical and functional rehabilitation services. The
incompleteness of the supply thus manifests as a lack of integration with the upstream side
of physical and functional rehabilitation, and then the lack of some component of physical
and functional rehabilitation (either physical therapy, or orthopaedic fitting, or more
frequently, occupational and speech therapy). As far as the downstream side of physical
and functional rehabilitation is concerned, it is only available in a few localities.
14
The case of Burkina Faso
The table showing the supply of physical and functional rehabilitation in 2009 in Burkina
Faso4 gives an initial idea of just how incomplete the supply is. Apparently, all of the
regions offered rehabilitation services in 2009. However, only nine out of thirteen regions
offered orthopaedic fitting services. But in Bobo Dioulasso, where there is surgery
(university hospital) and physical therapy, the private orthopaedic fitting shop just closed,
so now only eight regions have orthopaedic fitting shops. Lastly, only three out of thirteen
regions had CBR projects or programmes.
We were able to travel to Tenkodogo (Middle East Region), where the regional hospital
offers trauma surgery, though strictly speaking there is no orthopaedic surgeon. The shop
that was set up, thanks to Handicap International, provides orthopaedic fittings for the
regional hospital, though the technician was on temporary loan from the CNAOB, pending
the return of the regular technician, who is abroad for three years being trained with
Handicap International funding. For the time being, there is no physical therapy at the
Tenkodogo regional hospital and what exists nearby (e.g., at the CBR centre in Garango,
20 km away) is poor quality 5.
2.2 How access to physical and functional rehabilitation is organised in the
public health care sector
In the pyramid-shaped public health care systems typical of developing countries, physical
and functional rehabilitation can be accessed at several levels. The first level consists of
services at CBR centres 6 or other primary care centres. These offer advice and, in the best
of cases, physical therapy and even orthopaedic fitting services. The second level is that of
hospitals, where there are surgical and physical therapy services, and in some cases an
orthopaedic fitting shop.
4
Source: Stratégie nationale de développement de la réadaptation physique et fonctionnelle au
Burkina Faso [National strategy for expanding physical and functional rehabilitation in Burkina
Faso], a document produce dwith Handicap International support in November 2009.
5
A more detailed description of the rehabilitation supply in the Centre-Est region in 2010 can be
found in the report « Analyse des données en réadaptation de la région du Centre-Est », produced
by Handicap International in December 2011, in preparation for setting up the indicated orthopaedic
fitting shop.
6
See: Community-based rehabilitation: CBR guidelines, WHO, 2010.
15
The third level is dedicated to physical and functional rehabilitation, offering referral
physical therapy, occupational therapy, speech therapy and orthopaedic fitting services for
the country.
In many respects, this arrangement should be considered theoretical, because there are
generally gaps in the supply at the various levels of access. First, first level services do not
exist everywhere, and when they do, they may only be capable of disseminating
information. Next, the surgery available at hospitals is only rarely done by surgeons skilled
in orthopaedics. At district hospitals, the surgical skills are only a stopgap for when an
operation is necessary. In addition, not all hospitals offer physical therapy, even at the
regional hospital level. The possibility of orthopaedic fitting is, a fortiori, the exception.
What remains are the services at a physical and functional rehabilitation reference centre,
available in the capital and in regional capitals in certain countries, like Mali.
The case of Burkina Faso
According to the document on the supply of physical and functional rehabilitation in 2009,
the first two levels included no public rehabilitation facilities. That situation was corrected
thanks to Handicap International’s Tenkodogo project, which provides a second level
facility. The third level reportedly includes the CNAOB and the physical therapy services at
the three university hospitals.
2.3 Public supply and private supply
Like medical care, physical and functional rehabilitation services are dispensed in both the
public and private sector. The public supply is organised as discussed above. It uses
government-paid employees, either permanent or contractors. The fee structure is set by
the Ministry of Health. That supply has gaps, and may have been put in place only recently.
That explains, and even justifies, why private charitable services were established first, in
places where no public physical and functional rehabilitation services were available.
The private charitable supply is generally a stakeholder in the national supply, and may
receive temporary postings of public personnel. The fees tend to be higher than those in
the public sector, but exemption from payment is common (see below). The services and
the quality vary widely, and charitable services are primarily found at the first level.
16
The sector’s pyramid-shaped structure does not necessarily apply to the private
establishments, which have their own network of facilities and do not always refer patients
to the closest public facility.
In addition to the private charitable services, there are a few commercial services. These
services arise where there is a “niche”, that is, where there is demand for services by
people who can pay for them, and the quality of public services is deemed second-rate.
Such services do not necessarily aim to provide a full range of services; some offer just
physical therapy, and others orthopaedic fitting. This private physical and functional
rehabilitation may be connected to surgery clinics. The fees are obviously higher than in
the public or private charitable sectors. In some cases, the staff may also practice in the
public sector.
The case of Burkina Faso
Most of the physical and functional rehabilitation establishments are private charitable
facilities. There are thirty-two private faith-based primary care facilities and six CBR
projects. However, there are few private facilities at the higher levels. The exception is the
Paul VI Medical Centre in Ouagadougou.
The private primary care facilities provide information and physical therapy only. For
orthopaedic fitting, they refer patients (OCADES, for example) – sometimes quite far away
(e.g., to Tanguiéta, in Benin). They also do a significant amount of awareness-raising among
the population, and advise people on adapting their homes. In Ouagadougou (and probably
in Bobo Dioulasso, as well), there are private physical therapy practices. The Orthoba
company in Ouagadougou (which distributes PROTEOR products, primarily) has set up a
shop that makes orthoses and prostheses.
2.4 Financing the supply of physical and functional rehabilitation
From the provider standpoint, there are three potential sources for financing physical and
functional rehabilitation: out-of-pocket payments by users, private subsidies, and public
subsidies, in particular for paying staff. The situation in public and private facilities is
obviously very different.
17
While public facilities receive public subsidies, there are grossly inadequate. When physical
and functional rehabilitation operates within a hospital, it is not easy to separate it from
other hospital activities. The exception is salaries, which can be tied more easily to
personnel dedicated to physical and functional rehabilitation.
Though user payment is the rule, those self-raised revenues do not necessarily stay with
the facility, let alone with the physical and functional rehabilitation service.
Some public facilities receive outside subsidies from NGOs or partners in developed
countries. Those subsidies are often the only option for involvement in physical and
functional rehabilitation. Some NGOs may also place qualified personnel at the disposal of a
physical and functional rehabilitation service or facility. Such “free” personnel serve a care
giving and training function, which is not, in principle, sustainable.
Private facilities do not generally receive public subsidies, but may get public staff on a
temporary basis from the government. They make users pay, but that source of revenue
represents only a fraction of the operating budget. Most of their resources some from
outside subsidies related, for example, to their membership in a network. Either the
“motherhouse” allocates them a budget, or a private foundation gives them what they need
to operate each year. The sustainability of the outside funding is variable.
The case of Burkina Faso
The public facilities complain about the lack of public resources (the case with the CNAOB),
and seek outside subsidies. They do not get the out-of-pocket payments, which go to the
Treasury. The facility’s cashier’s office never even sees the payments for people receiving
free treatment (the indigent). Does the national solidarity fund pay them to the Treasury?
All this is obviously no incentive to boost activity, let alone the quality of the services.
The private charitable facilities express the same grievances with regard to their budgets.
Their own revenues reportedly cover only 25% of their costs (the case in Garango), or pay
only contractor salaries, bearing in mind that in charitable establishments, much of the
staff works on a volunteer basis (nuns providing physical therapy at Paul VI Medical Centre,
for example). Establishing a parallel between the activity at private charitable facilities and
their self-raised revenues is not easy. Fees are charged on a sliding scale basis, and free
services (physical therapy) are not uncommon. The rates for prostheses are somewhat
higher than the public rates, and exemptions are fairly rare. In the OCADES network, the
Light for the World Foundation’s contribution is essential. If it were eliminated, several CBR
centres would have to close. The physical and functional rehabilitation considered in this
18
study is not the only source of revenue for private facilities. They also charge for other
services, for the vision- and hearing-impaired. In addition, when the facilities order walking
aids or act as a middleman in the fabrication of prostheses, such services are paid for by
arrangement with the manufacturer, who is also part of the network.
2.5 Human resources
A crucial point for health care facilities wanting to offer physical and functional
rehabilitation services is having competent human resources, in a field that is not the most
highly-valued in the health care system. Rehabilitation physicians are rare in developing
countries, and not many surgeons specialise in trauma. Nor are physical therapists and
physical therapy assistants the most plentiful of ancillary medical personnel. Lastly,
prosthetics technicians are hard to come by, as are speech therapists and occupational
therapists.
The basic responsibility for this human resource shortage lies with the initial training of
doctors and ancillary medical personnel. When there are very few rehabilitation physicians,
often practicing in the armed forces, it is difficult to increase their ranks. In terms of
physical therapy, some countries do not train that category of ancillary medical personnel.
The result is that physical and functional rehabilitation quite often lacks the qualified
practitioners needed to expand its presence in the field. To get training, applicants are
often obliged to go to another country, or even a developed country, further delaying their
entry into the job market. And in a context of scarcity, trained personnel may be tempted
to go into private practice, rather than embark on a lower-paying career as a public
employee.
So it is easy to see why many physical and functional rehabilitation services are dispensed
by relatively unqualified staff (physical therapy assistants, for example), trained on the job,
who – despite their good intentions – are not an incentive for patients to follow the
treatments.
19
The case of Burkina Faso
In 2009, according to the study cited above, there were three rehabilitation physicians,
one orthopaedic surgeon, one high-level physical therapist, thirty-five physical therapists,
fifty-five physical therapy assistants, seventeen orthopaedic technicians and twelve
orthotic/prosthetic assistants.
If we consider people trained in degree programmes, there were thirty-six rehabilitation
professionals (twenty-one in the public sector, fifteen in the private sector) and seventeen
orthotics/prosthetics professionals (ten public and seven private).Yet applying the WHO
standards to the country’s population, there should be 143 people qualified in orthopaedic
fitting, and about ten times more physical therapists.
Unlike Togo and Benin, for example, Burkina Faso has no training for physical therapists.
There is, however, a training school for physical therapy assistants in Koudougou.
The Ministry of Health has a cooperative agreement with Belgium, and three people are
currently attending the Catholic University of Leuven for training as part of a Master’s
degree in physical therapy.
2.6 Supply for service providers
Manufacturing prostheses requires a supply of inputs.
Walking aids can be made from local or recycled materials. They can also be imported fully
assembled, or in some cases reused models sent by organisations in developed countries.
So providers have several distinct supply streams, resulting in variable costs for
prosthetics and materials.
For prostheses, local fabrication from inputs is most economical, but there is a whole range
of different quality products, depending on the basic input materials (see the pricing in
Tenkodogo, below).
For walking aids, equipment is usually imported. Private facilities receive used equipment
fairly often, as some NGOs distribute these types of walkers, canes and wheelchairs.
However, some local shops specialise in building tricycles, wheelchairs and walkers from
existing wheeled objects (motorcycles) and materials available in the country.
20
The case of Burkina Faso
What was observed during the mission suggests that the majority of Burkinabe providers
have chosen to make orthoses and prostheses locally, and to act as a middleman in
procuring mobility aids for patients. Thus, they buy the inputs for prostheses and order
ready-made walking aids. According to Orthoba’s director, the public facilities make do with
second-rate inputs, while he can offer more robust products using better-quality materials.
As an inputs broker, Orthoba nevertheless offers a range of quality, with the customer
choosing according to the price patients are willing to pay.
Wheelchairs and walkers are ordered from outside suppliers and, apparently, no physical
and functional rehabilitation service providers try to stock them. There are, in fact, few
local manufacturers. One exception is Karemsaba, a company that makes manual or
motorised tricycles (its specialty), crutches, walkers and canes. Their shop employs eight
people, and builds products to order. The wait for a tricycle is two to three weeks. The shop
reportedly produces 250 tricycles a year. The price for a tricycle ranges from 102,500 to
135,000 CFA francs (€156 to €206). A motorised tricycle costs from 250,000 to 400,000
CFA francs (€380 to €610), and is built from a motorcycle supplied by the customer. The
company operates thanks to a regular order from an NGO of about 200 pieces a year. It
also works with all of the country’s CBR centres, which occasionally submit orders. Though
the company has acquired a certain know-how, lack of easy access to bank loans makes
expansion problematic.
2.7 Geographical disparities in the physical and functional rehabilitation supply
Gaps in the supply of physical and functional rehabilitation services are obviously reflected
in very striking geographical disparities for those concerned. Those who live in big cities,
and especially in the capital, are favoured, while it is unusual for rural populations to get
physical therapy services, let alone orthopaedic fitting. The result is a barrier to access
that takes a variety of forms. First, people living far from facilities get less information.
Next, it takes longer to obtain services, which necessarily discourages some patients.
Lastly, it costs more to get to where the care or orthopaedic fitting is done, reducing even
further the number of people who decide to follow treatment or get a device. Hence the
cost of access to services is an important aspect of the cost to the user.
21
The case of Burkina Faso
Leaving aside occupational therapy (nonexistent) and speech therapy (only two
practitioners), the worst regional disparities are in orthopaedic fitting. In 2009, four out of
thirteen regions had no orthopaedic fitting facilities. In addition, an analysis of the
orthopaedic fitting data from the country’s regions showed average needs coverage of
0.02% in 2007 and 0.03% in 2008. That average is still low compared to the WHO
indicator. The study that was done before setting up the Tenkodogo orthopaedic fitting
shop indicated that the region had no orthopaedic fitting shops or orthoprosthesists.
Everyone seen in the five private centres whose disability required an orthopaedic fitting
was referred to Ouagadougou, Koudougou or Kaya. Travel costs are thus a curb to
accessing rehabilitation care. People with one or more physical or functional disabilities
have to travel long distances to get access to consultation and rehabilitation care in the
Centre-Est region. We estimate that, on average, a person travels about 50 km to get
access to physical therapy. The average distance for access to orthopaedic fitting (in
Ouagadougou, Koudougou or Kaya) ranges from 185 to 300 km. However, because people
generally need a number of physical therapy sessions over what are sometimes long
periods, while orthopaedic fitting requires only two to four visits to the centre every two to
four years, it is difficult to compare different services, and there are disparities
everywhere.
2.8 Financing the supply and the need for investment
The description of the physical and functional rehabilitation supply in developing
countries – and its illustration in the case of Burkina Faso – calls for some thought about
the system for financing physical and functional rehabilitation. The fact that users have to
pay significant amounts when they need orthopaedic fitting, mobility aids and even
rehabilitation services undoubtedly curbs access to physical and functional rehabilitation.
However, solving the problem of how to finance the demand – that is, lower the financial
barrier to physical and functional rehabilitation access to the level where households are
able to afford it – is not in itself enough to better finance the supply. The revenues that
users bring in to public and private facilities cover only a small portion of their operating
and investment needs. In many countries, the difference is made up, or reduced, by
subsidies from the government or elsewhere in the world. What results is a shortage of
qualified personnel and nearby facilities – supposing that operating costs are more or less
covered – to cope with a demand that is itself fairly weak, and certainly less than the actual
22
need. It is essential that countries put in place adequately-funded plans for expanding the
supply. The question is which mechanisms might improve the supply, given that the
standard public effort (facility budgets and staff compensation) is in itself inadequate in
both quantity and quality? Should we think about better coordinating outside subsidies?
The case of Burkina Faso
There is a specific programme for expanding the supply in Burkina Faso 7.
It uses a three-prong approach:
1. strengthening the institutional and organisational framework of the rehabilitation
system;
2. improving the technical equipment at rehabilitation facilities;
3. increasing the geographical accessibility of rehabilitation care in Burkina Faso.
7
Source: Stratégie nationale de développement de la réadaptation physique et fonctionnelle au
Burkina Faso, op. cit. p.12.
23
3. The cost to the user
3.1 The cost of services and orthopaedic fitting
The user has to pay for services according to set prices. While payment is generally outof-pocket, in some cases a third-party organisation may pay in place of the user (see
below). In theory, the cost of public sector services cannot be changed, because it is set
at the national level. There are some exceptions, however. Private charitable facilities,
on the other hand, report that they charge on a sliding scale, depending on the patients’
ability to pay. Hence the amount they ask for will differ from the posted prices.
The general principle for services is unit pricing; in Tenkodogo, for example, a
consultation or physical therapy session costs 1,500 CFA francs (for adults) or 750 CFA
francs (for children) (that is, €2.29 or €1.43, respectively). The facilities do not charge
flat fees, with one amount covering the entire treatment prescribed.
Prostheses and walking aids are also priced by the unit. Depending on the quality, the
most expensive device can cost twice, or even four times, as much as the least
expensive one. The facilities have a list of available products with their prices, which
tells patients how much they will have to pay.
The case of Burkina Faso
Based on the prices for orthoprosthesists services posted at the Tenkodogo regional
hospital (see appendix), we see that there is a different price for adults and children
(under age 15 years), with the latter generally getting a roughly 50% “discount».
Polypropylene transtibial prosthesis, for example, costs 120,000 CFA francs (€183) for
adult and 71,000 CFA francs (€108) for a child. That discount does not apply to betterquality products (made of resin), however, which cost about two-and-a-half times more.
As an example, an adult transtibial prosthesis can cost up to 300,000 CFA francs
(€457). The CNAOB’s prices are on the same order of magnitude.
24
3.2 Other access costs
People who physical and functional rehabilitation need have to get to where those
services are dispensed, which involves potentially significant transportations costs,
depending on the chosen mode of transportation. In principle, those costs are moderate
for physical therapy sessions if there is a primary care centre near the person’s home.
The cost increases, however, with distance, and in some cases with the how isolated the
person’s home region is.
When people need prostheses, the cost of lodging often has to be added to the cost of
transportation. An initial visit is needed to take measurements for the fitting. Then there
is a second visit for the trying-on and initial adjustment, which is normally followed by at
least one more visit for follow-up and adjustment. People who live far away have no
other option than to spend the night each time at the treatment location at potentially
significant expense, depending on whether they can stay with a family member or have
to pay for lodging.
The case of Burkina Faso
To get to Ouagadougou, where there is a full range of physical and functional
rehabilitation services, patients must pay somewhere between 12,000 and 16,000 CFA
francs per round-trip on public transport, depending on the location. The cost of the stay
is estimated to be somewhere between 8,000 and 15,000 CFA francs. Hence, for a
prosthesis requiring three contacts with a stay in the capital, the average cost might be
3 x 15,000 = 45,000 CFA francs for transportation and 3 x 12,000 = 36,000 CFA francs
for the stay, for a total of 81,000 CFA francs (or €123) in added costs. For an ordinary
transtibial prosthesis costing 120,000 CFA francs, that adds at least two-thirds the cost
of the service.
25
3.3 Lost income
Any illness or disability means lost income for working people. That cost is added to the
costs mentioned previously, and will be higher the longer the disability lasts and limits
the person’s job opportunities. The amount of lost income depends on the person’s
situation, with the biggest losers being those with the highest daily income.
3.4 Upstream and downstream costs
The costs of physical and functional rehabilitation always add to the costs of the medical
care preceding it, which may already be a burden for families, especially if they have to
pay for surgery or hospitalisation. The more difficult that burden is to bear, the greater
the propensity to do without physical and functional rehabilitation. Similarly, the cost of
adapting the home will add to the previous costs, and people may most readily decide to
do without that. Sometimes, the cost of adapting the home can be brought down by
using family and friends. Though pragmatic, that solution may not be possible when
major adjustments are needed. For example, people who live in town in small, multi-story
apartments may need to move if they use a mobility aid incompatible with the building’s
configuration.
3.5 Cost variability
We see that the costs associated with physical and functional rehabilitation will vary
depending on the location of available services and the situation of the individual in
question, and will be an important factor in the decision to start or continue treatment.
The existence of social security coverage will change the situation for all service
provider compensation costs, but will affect indirect costs more rarely.
26
4. Social security and the cost to the user
4.1 Social health insurance
The main purpose of social health insurance is to reduce the cost of health care services
to the user, whether for treatment or prevention. Without insurance, users must pay
out-of-pocket (paiement direct, in French) for fee-based care at the time of delivery.
Since the Bamako Initiative, most public facilities in developing countries fix the price of
their services, a longstanding practice in the private, charitable and commercial sectors.
This is a serious problem for most people and a key factor in their foregoing care and
prevention (the case with antenatal consultations). When care is unavoidable,
households face the possibility of “catastrophic expenditures” 8, and have to borrow or
sell their assets to pay for services or drugs. As has long been observed, this can lead
families into the “poverty trap”, and is ultimately an obstacle to development. The UN
agencies and World Bank became aware of this curb to development in the 1990s, and
ended up launching the Universal Health Coverage (UHC) project. The WHO has raised
this issue numerous times, and the 2010 and 2013 World Health Reports offer an
evidence-based argument for UHC 9. A variety of international events and commitments
by most States have established a consensus on the subject.
If teach project were to be summed up by a single maxim, it would be “replace out-ofpocket health care payment with prepayment”. Yet while all States have announced that
they are launching Universal Health Coverage (UHC) policies, there are as many ways to
achieve it as there are countries, and without details on how to get there, UHC rhetoric
by itself is not enough –independent of the fact that the experience of the WHO’s
“Health for All by the Year 2000” advocacy gives one pause about the agenda that will
be followed to achieve universal coverage.
In terms of UHC, governments presumably have two main options: going back to free
health care or establishing contributory forms of prepayment.
8
According to the WHO, a household’s health expenditures are “catastrophic” if they exceed
40% of the household’s capacity to pay (WHO, Distribution of health payments and catastrophic
expenditures–methodology, Discussion Paper Number 2, 2005).
9
See WHO World Health Reports: “Health systems financing: the path to universal coverage”,
WHO 2010; and “Research for universal health coverage”, WHO, 2013.
27
While free health care obviously poses the problem of sustainable sources of financing,
it poses technical problems as well, to wit:
- how to organise the monetary flows needed to allow health facilities to deliver free
services; and
- how to set up provider payment methods that incentivise efficiency.
Contributory forms of payment immediately bring health insurance to mind, with
inevitable questions regarding people’s ability to contribute, how risk will be managed
and how providers will be contracted with. The other contributory forms of prepayment
(subscription to health care facilities, health care vouchers and medical savings
accounts) raisemuch the same questions.
With respect to universal health coverage via free access to services, there are two
main approaches: a priori subsidies to facilities (supply-side financing), and a posteriori
payments to facilities based on invoicing, a method in which “the money follows the
patient” (demand-side financing). Economists consider first approach inefficient, though
that does not prevent many free health care initiatives from taking it. The experts
recommend the second approach, although it requires a management entity to monitor
and pay facility invoices. That entity would also have to take an interest in risk
management, in order to draw on funds, and would end up putting some forms of
provider pay-for-performance in place. Many systems put this principle into practice,
with a ministerial unit dedicated to the free health care initiative, equity funds (label
reserved for the indigent), and free vouchers.
With universal health coverage based on contributory forms, paying providers by
demand is automatic, and creating a management entity inevitable. Thus, both UHC
approaches require a management entity, but in contributory forms that entity is also
responsible for collecting the contributions/premiums from the people covered.
Compulsory health insurance, voluntary health insurance (mutual health insurance or
micro insurance schemes), health care purchasing funds, purchased vouchers and
medical savings accounts would have comparable mechanisms for dealing with the
operational problems of prepaid schemes based on demand-side financing. The health
insurance options are most common, and can easily be used to incentivise efficiency
among providers (pay-for-performance, for example) via registration, as it is usually
called.
To this brief introduction to prepayment methods we should add that no country
confines itself to one or the other of the foregoing approaches.
28
What exists is usually a hybrid between free health care and contributory forms of
prepayment (insurance, especially), raising the question of how these mechanisms work
together. The successful reforms in Ghana and Rwanda illustrate this.
The fact remains, however, that UHC does not necessarily have a specific place for
physical and functional rehabilitation services, and in most cases UHC mechanisms will
have to be extended to the disability sector.
4.2 Individual payment for physical and functional rehabilitation
The situation in developing countries is most commonly one in which patients must pay
out-of-pocket for physical and functional rehabilitation services at the time of care or
orthopaedic fitting. While there is seemingly a whole set of reductions in the amount to
be paid, such practices are random in nature and not really comparable to social
security mechanisms.
The most frequent case is that of adjusting the price to the person’s ability to pay
(sliding scale). This is a fairly common practice with private charitable services. Some
countries (like Togo, for example) use sliding scale fees in the public sector as well.
The second case is one in which providers act as brokers to find a third-party payer. For
children and adolescents, for example, the physical and functional rehabilitation provider
identifies someone who might pay for the prosthesis or treatment. Here the charity is
arranged by the provider, and this situation, as one might imagine, is likely to be found in
the context of parishes and for private charitable services. There is also some evidence
of this in the public sector, in particular in the context of public-private partnerships like
the one at Yopougon University Hospital in Côte d’Ivoire, where physical and functional
rehabilitation is offered by a private non-profit centre.
NGOs also enable free distribution of some equipment (canes and walkers) in both the
public and private sector. Some Social Affairs ministries also organise free consultations
or equipment distributions at times of the year that lend themselves to such donations
(Christmas and Ramadan), or as part of solidarity day or month celebrations (as in Mali).
It is hard to measure the scale of these donations, but they are often the only way to
improve the situation of people who are destitute. Many countries have established a
Disability Day, with equipment distributions (primarily walking aids) and limited payment
for certain treatments.
29
The case of Burkina Faso
The Karemsaba Company told us that a significant percentage of the wheelchairs that
an NGO orders from it are distributed at Christmas. Though it is impossible to know how
the beneficiaries of these donations are selected, we can hypothesise that they are
close to that NGO, which is Catholic.
At the Paul VI Medical Centre, a third-party payer is automatically sought when a
patient cannot afford prosthesis. The chief physician told us that an adolescent was
treated for several years in this way. Moreover, rehabilitation sessions are often free for
those who are destitute.
In Garango, near Tenkodogo, patients are asked to pay according to their means. In
addition, when people need prostheses they are sent to Kaya or even Tanguiéta, with
transportation arranged by OCADES.
4.3 Do the indigent get special treatment?
Exempting the indigent from payment for treatment, drugs and equipment is a constant
in health care in developing countries; still, we need to distinguish the different
principles and how they are applied.
In treatment situations, the facility’s social work department determines whether
patients are indigent via a standardised social survey. A file is opened and sent to the
appropriate (central or regional) social services or health agencies (depending on the
country). If approved, the facility is paid for the care by an ad hoc fund, which draws its
resources from the government budget. If the fund is exhausted, the facility does not
get paid. Exemption is therefore contingent upon the facility having a social work
department, creating a file, and sending it to the appropriate place and it being possible
to draw the money from a social fund.
Generally, for the indigent, payment exemption for physical and functional rehabilitation
care is no different than for ordinary medical care. But some countries (see the case of
Burkina Faso, below) may have a specific procedure for physical and functional
rehabilitation care for the indigent, once there is legislative recognition of disabled
status. Such recognition is fairly prevalent for disabled veterans, but less so for civilians
30
with disabilities. The principle is standard: a medical examination determines the degree
of disability, which entitles the person to a certain number of benefits, including partial
or total exemption from the cost of physical and functional rehabilitation services. The
indigent are exempt from any payment. The facility is obviously expected to know the
procedure and to follow it. Again, the actual payment exemption is contingent upon the
existence of an onsite social work department.
In three countries (Rwanda, Mali and Togo), Handicap International has set up equity
funds to pay for physical and functional rehabilitation for the indigent. In Vietnam,
Handicap International has also set up a fund at the rehabilitation centre where the
richer patients help finance the few poorer patients (who are in the minority) through
the price of their care.
The case of Burkina Faso
The National Solidarity Fund (FNS), which is administered by the Ministry of Social
Action and National Solidarity, is the primary financial mechanism for helping people
with disabilities who are unable to pay for care or equipment. The scope of the FNS’s
activity is not limited to people with disabilities, however; it also covers the indigent
elderly. The relative amounts going to each of these two areas does not seem to be fixed
beforehand, but according to the Director-General of National Solidarity (DGSN), about
two thirds of FNS benefits go to people with disabilities, and about a third go to the
elderly. In 2013, thirty-two million CFA francs were supposed to have been allocated to
charitable organisations caring for these two categories of indigents, nineteen million of
it for those serving people with disabilities. In all, the FNS reportedly spent thirty million
on disability, because support for the organisations is supplemented both by direct
support to individuals during Solidarity Month, where the FNS supplements NGO
assistance, and by funding actions aimed at adapting the environment (in particular,
making markets accessible via ramps). Those figures, communicated verbally, should
obviously be treated with caution. Allocation to disabled people’s organisations is similar
to supply-side financing, but operates on a case-by-case basis, according to requests
from the facilities’ social work departments. As regards funds allocated for mobility aids
only, the figure of four million CFA francs was cited by the DGSN, which indicated that
that was a maximum, suggesting that there is some pre-determined portion of FSN
31
funds for people with disabilities, and that once that amount runs out the allocations
stop.
The FNS’s operating methods on behalf of disability are not completely transparent.
First, it does not explicitly define how it selects organisations to receive subsidies. The
DGSN acknowledged that the Ouagadougou region is given preference. Second, it does
not monitor how the subsidies are used.
At the CNOAB, FNS payment for the indigent seems quite common, because the facility
has a social work department that takes care of putting together the applications and
sending them to the Social Fund. According to the Centre’s manager, the process is
successful in most cases. The funds are not traceable, however. In principle, the Fund
should pay the Centre and then the Centre should pay the corresponding amounts to the
Treasury, since it does not keep the money it receives. In practice, the Social Fund
notifies the facility’s social work department that it has agreed to pay, but Centre
receives no payment.
In Tenkodogo, while they know the procedure, they have not yet used it.
While the CNAOB knows about the disability card that gives the indigent free access
(see below), it has apparently not been used. The same is true at the Paul VI Medical
Centre.
4.4 Specific social security benefits for people with disabilities
When it exists in a country, disabled status is not just for the indigent. However, it is up
to the individual to take the steps necessary to have his disability recognised, which
requires establishing a file and going to a doctor. The agency authorised to provide the
elements needed for that procedure is the decentralised social services department,
generally based in the administrative centre of the region. The status is set by law, and
the procedures for obtaining the associated benefits by decree. A substantial amount of
time can elapse between enacting the law and publishing the application decrees, though
in some countries, knowing the exact state of disability status is difficult – is it
theoretical, or is it real?
32
Some countries have launched more or less sustainable initiatives aimed at giving more
social security benefits to people with disabilities, in particular by making access to
physical and functional rehabilitation free. Most countries have established a disability
day, on which they distribute technical aids (glasses, crutches, etc.) or give access to
certain services. Some countries have launched social welfare “extension” or
“reinforcement” projects for certain categories of vulnerable persons, such as the
elderly or people with disabilities, with additional benefits to specific groups (for
example, young people with disabilities). Such projects (see the case of Burkina Faso,
below) are in principle given a budget that should enable them to be carried out.
However, It is important to verify that:
- this is indeed the case, and that the funds will actually be paid out;
- there are plans to renew the operation for the next fiscal year, or at the very least that
it is being considered.
The fact that this kind of project is primarily political in function and is surrounded by
considerable hype makes this question even more legitimate. Obviously, such projects
should be more than just words.
The case of Burkina Faso
The mission identified two specific social security mechanisms for people with
disabilities: the disability card and measures to strengthen social welfare for people with
disabilities.
The disability card
As part of Law no. 012-2010/AN from April 1, 2010 to protect and promote the rights of
people with disabilities, article 3 institutes “a disability card for people with disabilities,
issued by the ministry charged with social action. A decree enacted by the Council of
Ministers sets the terms and conditions of issuing said card”. The card confers a set of
“benefits in the areas of health, education, vocational training, employment,
communication, social inclusion, transportation, housing and living environment, sports
and leisure activities, culture and the arts, and promotion of social action” (Article 4).
Articles 6, 7 and 8 of the law clarify the financial benefits in the area of health, in order
to “prevent or reduce exacerbation of the disability,” which would be “detected or
reported, in particular during the course of medical exams”; with regard to the indigent,
free consultations, care, ancillary testing, drugs, and hospitalisation in public health care
facilities, and free orthopaedic fittings, wheelchairs, tricycles, prostheses, white canes
33
and any other materials necessary to the care prescribed. For people with disabilities
who have a card but have not been declared indigent, there are discounts for public
sector care and orthopaedic fitting “proportional to the degree of disability”.
Strengthening social welfare
The government of Burkina Faso announced a 2013-2014 project to increase social
welfare benefits. The project was supposed to start in November 2013, and the
announcement was relayed by the media. The proposed amounts were significant, with
some 3 billion CFA francs supposedly going to disability. While the effort did indeed
target people with disabilities and the elderly, the amount that was announced implied
that other programmes would also be funded (perhaps universal health coverage? See
below). Unfortunately, the discussion with the DGSN did not clarify the amount that
would actually be mobilised, or according to what agenda. The DGSN mentioned a6
billion CFA franc measure in the government budget, with 1.835 billion to go to people
with disabilities and 885.375 million to the elderly. The DGSN indicated that the project
has four disability-related components. The first is aimed at providing health care for 50
people per commune or arrondissement (for Ouagadougou and Bobo Dioulasso), that is,
368 territorial entities and 18,450 people with disabilities, at 25,000 CFA francs per
capita. The amount allocated is thus 18,450 x 25,000 = 461.25 million CFA francs. Those
people would be designated at the local administrative level.
The second component is to fund individual micro projects for 1,200 people with
disabilities at a lump sum of 350,000 CFA francs each, for 1,200 x 350,000 = 420
million CFA francs. A quota of beneficiaries would be established by province and by
region.
The third component is aimed at acquiring materials, for a total of 444 million CFA
francs.
The fourth component provides comprehensive care for 500 children with disabilities,
for a total of 600,000 CFA francs per year, i.e., 500 x 600,000 = 300 million CFA
francs.
Based on the information from the DGSN, the budget for all four components comes to
1.625 billion CFA francs, which – given the figure reported above – would leave an
“unallocated” total of 210 million CFA francs. We will not belabour the lack of precision
in these figures, or the conditions for managing the project’s funds. There is apparently
a ministry-level steering committee, and a management entity designated by the
governor in each region.
34
The government project, run by the Ministry of Social Action and National Solidarity,
was apparently not prepared in consultation with disabled people’s organisations. The
DGSN indicated that an informational meeting for them was going to be held on 7
November 2013. The federation of associations – met with during the mission on
Tuesday, 5 November – had just received the invitation.
We are obviously somewhat sceptical about this project. Though it is clearly political in
nature, it could improve the situation of people with disabilities, even if only partially
carried out. Also, it should be budgeted for again in 2014.
4.5 Universal coverage and compulsory health insurance
Physical and functional rehabilitation procedures, prostheses and mobility aids could be
totally or partially paid for as part of universal health coverage. But since few West
African countries have UHC, it is difficult to know whether the basket of care will include
them.
We can get a better idea of how physical and functional rehabilitation is addressed in a
health care coverage system by looking at already-functioning compulsory health
insurance (CHI) schemes, although these concern only the formal sector (salaried
company employees and civil servants). There are compulsory health insurance schemes
for salaried employees in Mali, Guinea, Gabon and Senegal. Their performance varies
widely. In Mali, the scheme is recent; in Guinea, it is old but non-functional; in Senegal, it
is decentralised (IPM); and in Gabon, it was reconfigured as part of UHI. Physical and
functional rehabilitation is not explicitly covered by these schemes. The most likely
assumption is that physical and functional rehabilitation may be paid for on a doctor’s
advice, on a case-by-case basis.
The situation is better in schemes covering occupational injuries and diseases. Most
West African countries have instituted schemes covering such risks. In principle, at
least, physical and functional rehabilitation are paid for in that context. We note,
however, that those schemes are often quite profitable, which indicates that while
employers pay the contributions, few services are provided. In this regard, it is
instructive to recall that Senegal’s social security fund’s Board of Directors came up
with the idea of using the reserves to build an orthopaedic hospital in Dakar.
35
Though the project was completed successfully, the facility turned out to be a financial
black hole. It had to be converted back into a general hospital; it is now the Grand Yoff
General Hospital.
The case of Burkina Faso
Burkina Faso is currently setting up universal health coverage based on universal health
insurance (UHI). While there have been numerous meetings and several documents
published, it is hard to give specific details on what that universal coverage will include,
since the basket of care has not yet been established. Nor has the institutional structure
been fully determined.
The launch of this major project has caused tension in a variety of ways. There disinterministerial tension, because UHC could be run from either the Ministry of Health or the
Ministry of Civil Service, Labour and Social Security. The second has won, in that it is the
home of the permanent Steering Committee charged with setting up the UHI. That
committee includes all of the stakeholders, and must produce the institutional and
technical proposals necessary to the actual launch of UHI. The permanent committee’s
work should continue throughout 2014, because the agenda does not anticipate the UHI
launch until 2015 10. A second source of tension has to do with the role of mutual health
insurance schemes (mutuelles) in UHI. The mutuelles, which manage voluntary health
insurance plans (see below), have refused to be relegated to the role of service counter
and premium collector, and have been allowed to participate in the Committee’s work.
Exactly what their role will be, however, remains to be determined.
Pending the launch of UHI, the social security scheme for salaried employees offers “old
age”, “family”, and “occupational diseases and injuries” benefits. The National Social
Security Fund (CNSS) manages all three arms of the scheme. The Fund thus intervenes
in cases of occupational injury, and will pay for physical and functional rehabilitation for
the salaried workers concerned. The CNSS and the CNAOB have an agreement, and the
Centre confirmed that this social security mechanism was indeed functioning for
payment of rehabilitation, prostheses and mobility aids. The CNSS also has an
agreement with the Bobo-Dioulasso University Hospital, but there it only covers
10
See, for example, the presentation by Yaméogo J.B. and Sanou A., Processus de mise en place
de l’assurance maladie au Burkina Faso, Ministry of Civil Service, Labour and Social Security,
Permanent Secretariat for Health Insurance, Ouagadougou, 28 February 2013.
36
rehabilitation. The other regional hospitals should (or are going to) have agreements, but
at Tenkodogo, for example, the mechanism is not yet functional.
Civil servants, on the other hand, have government-paid health insurance that is limited
to hospitalisation in the public sector (the four-fifths rule). The corresponding services
are managed by the Caisse autonome de retraite des fonctionnaires (CARPFO). This
should in principle include a contribution to physical and functional rehabilitation care,
but we assume that that is decided on a case-by-case basis.
The workforce concerned by these mechanisms corresponds to formal sector
employees, and thus to about 10% of the population.
4.6 Mutual health insurance
Mutual health insurance societies represent a fairly heterogeneous collection of
organisations 11; those of greatest interest here are the ones that offer health insurance
policies. In theory, the coverage offered by mutual health insurance schemes – that is,
the basket of care they pay for – could include physical therapy and prostheses. Physical
therapy does not pose any serious problems, provided there is an agreement between
the mutual health insurance organisation and the facilities offering the services.
The cost of prostheses and other walking aids, on the other hand, is generally beyond
the financial means of such organisations, which are often small and poorly-funded. At
first glance the problem appears to be due to the unit cost of these services, since
relatively few people need them. But we have to consider the usual voluntary health
insurance schemes the mutual health insurance organisations offer, and how that puts
them at high risk of adverse selection 12. For example, if mutual health insurance
coverage includes prostheses for a moderate premium, people needing prostheses will
tend to join, because they already plan to get such devices paid for.
11
See Letourmy A. and Pavy-Letourmy A.: « La micro assurance de santé dans les pays à
faiblerevenu », AFD, Notes et documents n°26, December 2005 and the case of Burkina Faso,
below.
12
Adverse selection, or anti-selection, is behaviour by individuals who decide to insure
themselves because they know they are at high risk, in this case in poor health or already
disabled.
37
Low frequency is therefore a shaky assumption when membership is voluntary, and to
keep their premiums reasonable mutual health insurance organisations will tend to
exclude orthoprosthesists fittings from their coverage. That is tantamount to selecting
members and to penalising people who develop a disability after joining, since they
would be paying for coverage that no longer suits their situation. In this scenario it is
hard to reconcile the interests of the insured with those of the insurer without
substantially increasing the premium. In other words, the mutual health insurance
organisations could offer a coverage option that includes orthopaedic fitting, but at a
high premium, because it is calculated in the expectation of adverse selection. Such
organisations would have to be technically sophisticated enough to manage a variety of
different coverage options, and be aimed at well-off customers. This is not at all the type
of organisation found in developing countries.
Three things should be noted, however. First, mutual health insurance schemes could
pay on a case-by-case basis, on behalf of an injured member, for example. Paying for
prostheses, unadvertised, would not penalise those who acquired a disability after
joining. Second, physical and functional rehabilitation could be paid for via reinsurance.
The mutual health insurance organisations would no longer have to carry the risk
represented by orthopaedic fitting services, which they would transfer to a higher-level
insurer, called the reinsurer. The latter could reinsure a group of mutual health
insurance organisations, in order to spread the risk over a larger number of people. This
is not an ideal solution, however, in that it does not eliminate the risk of adverse
selection and would automatically increase the premium for each mutual health
insurance scheme, since the reinsurance premium – paid by members of the basic
mutual insurance organisations – is added to the premium without orthopaedic fitting.
The reinsurance premium is simply less than the additional premium that the basic
mutual insurance organisations would have to charge if they carried the orthopaedic
fitting risk themselves. Lastly, in developing countries, this reinsurance option assumes
a certain maturity in the mutual insurance movement, because reinsurance must be
situated at the union or federation level 13. Few countries have a high enough level of
mutual federalism for this. There is the case of Mali, with its Union Technique de la
Mutualité Malienne (UTM), but the UTM’s progress, which has failed to live up to
expectations, is now most likely insufficient for offering reinsurance.
13
Reinsurance by commercial reinsurers like SCOR or Munich Re is obviously not an option, since
it would be too expensive.
38
The last solution is coinsurance – that is, splitting the risk represented by people with
disabilities between the basic mutual insurance organisations and a co insurer. In this
case, the basic mutual insurance organisations would continue to carry and manage the
risk of ordinary illnesses, while the orthopaedic fitting risk would be carried by the co
insurer. This solution assumes that a co insurer consenting to the arrangement can be
found which is fairly problematic in developing countries. In practice, it would be
appropriate to replace the co insurer with a special fund that has public status and that
draws its resources from the government or from outside or private charitable donors.
That arrangement has been used in Tanzania for HIV/AIDS-related risk, with the Elton
John AIDS Foundation 14 acting as a “co insurer” for the basic mutual insurance
organisations. In that set-up, risk management is left to the mutual insurance
organisations, which assumes that they are sufficiently capable of managing the healthrelated risk.
More generally, the value of the mutual insurance organisations is that they offer
management capacity that might be used as part of a physical and functional
rehabilitation financing mechanism that draws its resources from a variety of donors
(the government, bilateral or multilateral cooperation, and private foundations). That
function of managing resources that do not come from members –a possibility for
disability-related risk –might also apply to all free-care initiatives, like those related to
childbirth (caesarean sections, in particular) and medical care for young children. Two
conditions would obviously have to be met: the mutual insurance organisations would
have to have real management capacity, and those donating to free-care initiatives
(government or outside donors) would have to agree to delegate management.
14
Galland B., Guillebert J., and Letourmy A. A public/private partnership experiment in the area
of social health protection in Tanzania, FACTS Reports, Special Issue 8/2013.
39
The case of Burkina Faso
Mutual health insurance schemes have been growing in Burkina Faso since the early
1990s, but have not yet achieved a strong position in the health insurance field.
A survey of social mutual insurance organisations, conducted in 2011 on the initiative of
the NGO ASMADE 15, gives an idea of their situation. It found 205 organisations; while
188 were functional, 115 of those were having operating difficulties.
The social mutual insurance organisations were classified into five groups: conventional
mutual health insurance organisations, professional mutual insurance organisations,
cost-sharing systems, prepayment systems and solidarity funds. In fact, only the first
two groups include organisations offering voluntary health insurance schemes, as the
other three are similar to health care provider-initiated set-ups. In any case, these two
groups are the largest in terms of both quantity and the number of people covered.
According to the inventory, there were:
- 131 mutual health insurance organisations covering 95,082 beneficiaries;
- 38 professional mutual insurance organisations covering 136,621 beneficiaries;
- 22 cost-sharing systems covering 5,855 beneficiaries;
- 9 prepayment systems covering 17,642 beneficiaries;
- 5 solidarity funds covering 815 beneficiaries.
The total number of beneficiaries is a very modest 256,015, for a coverage rate of 1.8%.
Moreover, the survey figures should be viewed with caution, since only 44% of
beneficiaries are apparently up to date on their contributions – 37% for the mutual
health insurance organisations and 53% for the professional mutual insurance
organisations, the three other categories having very low contribution recovery rates.
It is easy to see from these figures that the mutual health insurance organisations are
small in size. According to the survey there were 103,373 premium-paying members,
with an average of 767 members per unit.
The creation of the mutual health insurance sector in Burkina Faso has been
fragmentary, which for the moment has prevented a true movement from forming. That
fragmentation is due, in part, to the external sources of support, which have been
unable, or unwilling, to connect the projects they fund, thereby creating independent
promotion and support structures, despite the existence of a Cadre de Concertation des
15
Bationo F. and Zett J.B., Inventaire des mutuelles sociales dans la perspective de l’assurance
maladie universelle au Burkina Faso, ASMADE, October 2011.
40
Structures d’Appui aux Mutuelles de santé (CCSAM). It is also due, in part, to the
Burkinabe government, which has failed to define a coherent policy, and which has
allowed tensions between ministries to continue –as illustrated by the situation with UHI
(see above). Also (and especially), the quality of care in the public sector has given the
population little incentive to subscribe to voluntary health insurance.
All of the mutual insurance organisations can be described in terms of the support
structures to which they are attached, four of these substantial in size: the Association
de Développement de la Région de Kaya (ADRK), the NGO ASMADE (Association
SonguiManégré/Aide au développement endogène), the RAMS (Réseau d’Appui des
Mutuelles de Santé), and the NGO BØRNEfonden. To these groups, which represent
mutual insurance organisations targeting the informal sector and rural areas, we should
add the professional mutual insurance organisations targeting the formal sector.
During the mission we met with leaders from RAMS and ASMADE, as well as with an
advisor to the Fédération des mutuelles professionnelles (federation of professional
mutual insurance organisations).
The RAMS is funded by a group of partners: by Belgian organisations connected with the
Christian mutual insurance organisations, by the French Mutualité Sociale Agricole, by
the Dutch development organisation SNV, and by the European Union via PROS, a
capacity-building programme for civil society organisations. It supports some thirty
functioning mutual insurance organisations representing 10,468 members and 34,120
beneficiaries, or more than a third of the country’s mutual insurance organisations. The
RAMS presents itself as the leader in mutual health insurance promotion and support in
the country. It does, in fact, support mutual insurance organisations in several regions. It
has projects to create communal mutual insurance organisations and a union of mutual
insurance organisations managed centrally in Kaya. The RAMS has good contacts with
the Ministry of Social Action and National Solidarity, and was supposed to be involved in
Solidarity Month, to sign 4,800 indigent people up for mutual health insurance using
public funds. But the project, designed in 2011, has yet to become a reality. There are
also plans (EU project to be finalised) to get the RAMS involved in managing the free
health care initiative for children ages 3 to 5 years.
ASMADE is an NGO funded by the socialist mutual insurance organisations in Belgium,
and is also connected with the CIDR, a French NGO that specialises in supporting health
protection and mutual health insurance schemes. It was involved in producing technical
reference documents on setting up mutual health insurance organisations 16 and in
16
See ASMADE, Processus de mise en place de mutuelles de santé, document de capitalisation,
41
actively lobbying the Burkinabe government during the process of establishing UHI.
ASMADE supports twenty or so mutual insurance organisations and has set up
computerised management, which will be the starting point for outsourcing
management. It is part of the RAMS and represents the mutual health insurance
organisations on the UHI steering committee, where it has taken the place of the RAMS,
which was relatively inactive.
The professional mutual insurance organisations are mutual insurance organisations for
civil servants or businesses. They do not specialise in health, and not all offer voluntary
health insurance. For example, the Ministry of Economy and Finance has six mutual
insurance organisations; the Treasury, Tax and Customs mutual insurance organisations
have health insurance. Some public companies, such as Sonabel (electricity) and Onatel
(telecommunications), and private companies, like the main banks, Lonab (the national
lottery) and the daily newspaper l’Observateur, have not formally created mutual
insurance schemes, but offer their employees “house” health insurance, whose services
are not always managed in a transparent way. The professional mutual insurance
organisations have their own federation, whose role is apparently not management, but
only representation. The student mutual insurance organisation, MUNACEB (Mutuelle
des Etudiants) – whose premium (5,000 CFA francs, or €7.6, a year) is free for grant
holders – is also a member. The professional mutual insurance organisations can be
considered relatively well-off, due to the status of their members. The future UHI is
expected to include compulsory insurance for the entire formal sector, which will be
managed by an independent fund. The professional mutual insurance organisations will
then be encouraged to offer supplementary services, with the result that they will be
less attractive.
As a whole, mutual insurance organisations represent an interesting possibility for
helping to fund physical and functional rehabilitation, provided there is a significant
effort to involve them in the disability sector and a discussion on financing. Thus far,
none of these mutual insurance organisations includes physical and functional
rehabilitation in its coverage. The necessary management capacity could be developed
at the support network level. We should note that the support networks are still
associations, like the mutual insurance organisations themselves. Mutual status, as
required by UEMOA regulations, has not yet been incorporated into Burkina Faso law.
April 2013.
42
4.7 Other insurance
Other types of insurance can be used to pay for some or all physical and functional
rehabilitation care or prostheses – for example, commercial insurance companies with
their “health” products, or more likely with products that cover “motor vehicle” risks.
This assumption has two caveats. The first has to do with the motor vehicle insurance
requirement in developing countries, which at most applies only to automobiles, and
which is in many cases only partially complied with. The second has to do with the
policies’ coverage in case of accident; do they automatically include bodily injury to the
driver and his passengers?
The case of Burkina Faso
Insurance is required for cars, but as far as we know, the coverage offered on the
market covers third-party risks and does not specify intervention in case of bodily
injury. One might also wonder whether this requirement is actually respected. Insurance
is not required for “two-wheel” motorised vehicles, which are responsible for many
accidents and disabilities. While there is a law requiring helmet wear, it is absolutely not
obeyed and not routinely enforced.
4.8 Health care purchasing funds and other prepayment systems
One would imagine that health care purchasing funds, which combine various sources of
financing
(subsidies
and
contributions),
would
cover
physical
and
functional
rehabilitation care and prostheses. The situation is the same as for health insurance
organisations; the only difference is the type of organisation paying the providers.
Some experts recommend the purchasing fund model as a solution for combining
resources from different sources (pooling), and for putting the emphasis on contracts
with health care facilities (purchasing). To the best of our knowledge, there are only a
few examples of these in the field (e.g., the DRC), and they are dedicated to conventional
care and not to physical and functional rehabilitation. However, physical therapy
sessions and prostheses could easily be included in the services they buy.
43
Similarly, a voucher system could also be applied to physical and functional
rehabilitation. This mechanism can be free of charge, and be used to give access to the
indigent, especially for primary care and maternal and child health care (Cambodia). In
that case it is like an equity fund. It can also be paid, in the form of a voluntary
contribution, with people buying a voucher for a treatment dispensed by authorised
providers. An experiment with “paid” vouchers for pregnancy care and delivery is about
to be launched in Cameroon.
44
5. Capacity for change in the economic system for physical and
functional rehabilitation
The foregoing information clearly indicates that the economic system for physical and
functional rehabilitation in developing countries is inadequate or unorganised. There are
gaps both in the supply of physical and functional rehabilitation services and in the
various financing mechanisms that could be used to remove the financial barrier to
accessing those services.
In other words, the economic system for physical and functional rehabilitation is fairly
rudimentary, and as a result there is a fairly low level of activity. We cannot stop at that
assessment, however, insofar as the system in each country is destined to evolve. We
should in any case evaluate how it might move forward, with a view to organising
advocacy efforts or setting up field projects. This requires analysing both the political
and financial context of physical and functional rehabilitation and the players involved in
that sector.
5.1 National disability policy
The capacity for change with regard to physical and functional rehabilitation depends on
the policy on helping people with disabilities. The priority given to the inclusion of
individuals in education and employment, and past and future efforts on behalf of the
sector of services aimed specifically at them, differ from country to country. An initial
aspect of the policy relates to the governments’ willingness to include the rights of
people with disabilities in their legislative or regulatory texts.
When it launched the DECISIPH programme in six West African countries, Handicap
International assessed the legal framework in favour of people with disabilities in West
Africa 17. At the time of the assessment (2011), several of the countries had enacted
general laws: Burkina Faso (see below), Senegal (Social guidance law of July 26, 2010 on
the promotion and protection of persons with disabilities) and Togo (Act of April 23,
2004 on the social protection of persons with disabilities (no implementing decree).
Other countries have legislated by order, which is a bit less politically significant, like
17
See: DECISIPH, Legal Framework Governing Disability Rights – Burkina Faso, Mali, Niger,
Senegal, Sierra Leone and Togo, December 2010.
45
Niger (Ruling No. 93-012 of March 2, 1993 as amended and supplemented by Ruling 028
of May 28, 2010 and Decree No. 2010-637/PCSRD/MPPF/PE of August 26, 2010 laying
down procedural requirements for Ruling 93-012 of March 2, 1993 as amended and
supplemented by Ruling 028-2010 of May 28, 2010). Others had dealt with the situation
of people with disabilities in a text centred on another theme, like Mali, with Articles 46
and 47 of Act No. 99-046 on the education law. Lastly, others had a specific law on
people with disabilities, but had not yet voted on or enacted it, like Mali (Persons with
Disabilities Bill, since 2009) and Sierra Leone (Persons with Disabilities Bill, since 2007).
But how such provisions are applied may not reflect the government’s commitment. In
fact, the actual nature of these texts has yet to be verified; that is, the exact conditions
of their application in the field need to be established. The political will and capacity with
respect to disability are measured first by observing the strategy for developing the
sector and the degree to which those agendas are followed. Next, public budgets
dedicated to the sector are a good indicator of the effort being made on behalf of people
with disabilities. These budgets can be reconstructed in a pragmatic way by adding
together allocations to facilities (provided in the health care budget) and social service
payments. In addition, financing physical and functional rehabilitation services requires
coordination between ministries – in particular, between the ministries in charge of
health care, social services, social security and finance. The existence of a national
disability council (which would also include representatives from NGOs and disabled
people’s organisations) is an indication of the how much attention the sector is
receiving.
46
The case of Burkina Faso
There are several laws providing a legal framework for disability rights: the Framework
Law for Persons with Disabilities, Zatu No. 86-005/CNR/PRES of January 16, 1986; Act
No. 003-2010/AN of January 25, 2010, amending Act No. 014-2001/AN of July 03, 2001
on the electoral code; and Act No. 012-2010/AN of April 1, 2010 on the protection and
promotion of persons with disabilities. It is the last text that provides for real “person
with disability” status and the above-mentioned disability card.
A national strategy to expand physical and functional rehabilitation for the 20112020period was drafted in November 2009 18. It states that “rehabilitation is the fourth
component of health care, after preventive care, curative care and promotive care”, and
also that “it is poorly-developed in Burkina Faso’s health care system”.
On several occasions we saw situations in the field where it seemed that physical and
functional rehabilitation was not, in fact, getting much consideration at the policy level.
The DGSN even acknowledged that “in reality, people with disabilities were not a high
priority”.
Several ministries are involved in the national policy. These include the Ministry of
Health for facilities and services; the Ministry of Social Action and National Solidarity for
financial payment and specific actions; the Ministry of Civil Service, Labour and Social
Security for social security; the Ministry of Youth, Professional Education and
Employment; the Ministry of National Education for schooling; and, inevitably, the
Ministry of Economy and Finance for budget decisions. And there are others (Sports, for
example), but the main concern is whether there is any coordination between these
institutions. Article 56 of Act No. 012-2010/AN stipulates that “a multi sectoral
coordination, monitoring and evaluation body is put in place to ensure the effective
application of the provisions of the present Act.” That body is, in fact, the “armed wing
of the DGSN”, which suggests that a single ministry, National Solidarity, is responsible
for disability policy.
Source: Stratégie nationale de développement de la réadaptation physique et fonctionnelle au
Burkina Faso, Op. cit.
18
47
5.2 Public and private players
Human resource development comes from having well-known professionals. But the
scarcity of physical and functional rehabilitation professionals in a given country limits
their influence. They can, however, form associations. For example, “in Burkina Faso
there are three professional associations that work to improve the quality of care
through theme-based continuing education for members:
•
the Association Nationale des Techniciens Orthopédistes du Burkina (ANTOB);
•
L’Association Burkinabé des Masseurs Kinésithérapeutes et Auxiliaires de
Rééducation (ABMKAR);
•
Rééducation Pour Tous (REPTO).
While the existence of pan-African associations 19 is a valuable means of recognition for
individuals, it is not necessarily ideal for giving impetus to a national process.
Other influential players can be found in the charitable sector. While the supranational
networks to which they belong give them additional means of action, such networks may
encourage them to be less involved in national processes that might lead to changes in
the country’s physical and functional rehabilitation. From a certain point of view, these
players do not have high expectations of the government, and while they willingly
participate in public service, they tend to be more oriented toward the outside and
focused on getting more resources to expand their own activities. For example, Catholic
organisations rely on pan-African foundations, and try to reinforce their presence by
using outside resources to support the activities of volunteers active at the parish level.
The volunteers provide outreach support for people with disabilities based on
awareness-raising and information, and not exempt from religious proselytising. In doing
this they are working, by implication, in the same arena as the lay patient associations,
and these, on the whole, do not even benefit from the modest resources they can
mobilise.
Another interesting thing to consider when assessing the potential influence of the
sector’s players is the dynamism of the equipment suppliers. Commercial players are
often well-aware of the possibilities for increasing demand, and can create new ways to
access products.
19
For example, the Fédération Africaine des Techniciens Orthoprothésistes (FATO).
48
Lastly, sources of outside support may get things moving. While the disability sector has
a fair number of them, many specialise in the types of disability excluded from this study
(visual disabilities, for example). Outside players bring a variety of resources in the form
of donations, training, and support for civil society. They will be all the more likely to
bring
change
because
rather
than
confining
themselves
to
local
projects
(experimentation), they get involved in projects that are national in scope. The question
is whether outside players are willing to establish partnerships with government, either
on subjects of general disability policy (cf. the DECISIPH programme mentioned above)
or in operational systems in the field.
5.3 Civil society
Disabled people’s organisations should be the government’s privileged interlocutor, and
are themselves able to create facilities for people with disabilities in some cases. There
are many associations and we should distinguish between those that grow out of
initiatives in developed countries and those started by a few local individuals.
In terms of networks and action levers, associations are generally only as good as their
leaders. Such associations can be fairly resource-poor. Occasionally they are supposed
to receive grants from the government (national and local) or outside partners. Not all
associations have chapters throughout the country, which limits their ability to inform
and advocate.
Some associations consider informing individuals their primary function. This comes
from having very few resources, which discourages them from acting as service
providers. There may also be conflicts or a lack of coordination between associations.
The case of Burkina Faso
Two major groups of disabled people’s organisations were identified in Burkina Faso.
The older of the two is FEBAH (Fédération burkinabé des associations de personnes
handicapées), which federates a large number of associations throughout the country.
FEBAH derives some of its influence from the connections of its president, who is a
member of the National Assembly. She founded a school, whose director is also the
executive director of FEBAH.
49
The second group is the network RENOH (Réseau national des organisations de
personnes handicapées), led by the former executive director of FEBAH. The latter, in
dispute with the president of FEBAH, runs CEFISE (Centre d’éducation et de formation
intégrée des sourds et entendants), which was created by her late husband. CEFISE is a
Handicap International partner in vocational training.
FEBAH has member organisations in several regions. During the mission, we were able
to meet with the president of CORAPH/CE (Coordination régionale des associations de
personnes handicapées du Centre Est) (Tenkodogo) and member of FEBAH’s board of
directors, including its executive director. CORAPH’s membership includes twenty-five
associations in three of the region’s provinces, which together represent from 1,000 to
2,000 people with disabilities. Its main function is to give new patients information on
the region’s CBR centres, orthopaedic surgery services (in Kaya), prices, and the
Tenkodogo physical and functional rehabilitation centre. CORAPH operates with about
fifteen volunteers. While the associations are not involved in organising service delivery,
they sometimes act as go-betweens to help individuals obtain walking aids (crutches,
especially). CORAPH is primarily an advocacy group with respect to the government;
because it gets no grants to develop real projects. It is involved in organising the
International Day of Persons with Disabilities (3 December). It offers association training
with Handicap International support, and while it would like to manage a regional action
fund (modelled on Mali’s Handi-Caisse), it has little hope of doing so, due to what is sees
as government inertia.
FEBAH’s leaders do not have much good to say about the government’s action, either.
They stress the importance of getting information to remote populations, and feel that
FEBAH’s role is provider referral, and not creating and running facilities itself. FEBAH
complains about the level of National Solidarity subsidies and the associations’ meagre
involvement in disability sector governance. In this, FEBAH is tacitly criticising the
DGSN, which acts without consultation –as an example, there are no association
representatives on the FSN’s board of directors. FEBAH is trying to establish closer ties
to the Ministry of Health in order to strengthen the CNAOB, which it feels is incapable of
meeting the demand.
50
5.4 Establishing universal health coverage
The prospects for changes in health coverage are important for transforming the
economic system for physical and functional rehabilitation. The dynamism and political
leadership of universal coverage-related reform will determine the degree of impact on
the disability sector.
The case of Burkina Faso
The Permanent Secretariat for Universal Coverage is supposed to define the basket of
care that will be offered as part of UHI. If it is felt that rehabilitation and orthopaedic
fitting should be included, even if subject to certain conditions, that message must be
delivered and defended at UHI steering committee meetings. Just as the mutual
insurance organisations (ASMADE) actively lobbied to defend their positions and
regularly attended meetings, disabled people’s organisations should strive to participate
in the work, and prepare a set of arguments and a consensus proposal within their
federations. FEBAH is probably best placed to play that role, if only by virtue of its
president’s position – provided the tensions between organisations can be defused and a
common position defined.
51
Conclusion
Our analysis of the economic system for physical and functional rehabilitation
undeniably argues for the development of financing tools that enable better access to
services. At the same time, it shows that the sector represents an inadequate supply
with respect to the assumed needs, and that the supply lacks the human and financial
resources it needs to expand.
If financial access to physical and functional rehabilitation was improved, activity at the
existing facilities would increase until the available human resources were saturated. If
that additional activity did not make it possible to recruit more staff (assuming there
were people to recruit) or open more facilities (assuming the surplus revenues could be
directed toward that kind of investment), the supply would still be inadequate. Yet with
the current price structure, this is probably the scenario right now. Paradoxically, prices
are too high for users to afford, but too low for facilities to operate properly.
Hence, while better financial accessibility will benefit some (which is already a lot), it will
not solve the problem of financing the sector, and this will prevent the majority of
people with disabilities from receiving care. In that sense, a mechanism for free
universal care might actually be discriminatory, primarily benefitting those who live near
facilities. Granted, waiting until there is enough supply before facilitating access to
existing structures for those who need it is not possible. But there is no way that
supporting (subsidising) demand is going to be enough.
Furthermore, the free health care systems already in place have not radically altered
the physical and functional rehabilitation situation. One need only look at the evaluation
of the equity funds set up by Handicap International in Mali, Togo and Rwanda 20. Despite
the financial effort, the funds had only a marginal effect, “due either to the lack of
technicians (Rwanda and Mali) or to the limited budgets allocated to them (Togo)”.
20
See B. Gerbier and R. Botokro. Improving access to rehabilitation care for the poorest:
evaluation of the 3 equity funds set up by Handicap International in Rwanda, Mali and Togo.
Handicap International, 2009, Op. cit., p. 27
52
Two important principles can be drawn from this:
- First, investment in the physical and functional rehabilitation sector should not be
neglected in an effort to support demand.
- Second, the mechanisms needed to facilitate financial access to physical and functional
rehabilitation should be as equitable as possible, and thus designed to consider all of the
costs to users, not just the applicable fees.
In some countries, the government might be open to financing experiments that would
hopefully be continued. While the situation in Burkina Faso is probably not the only
reference, the most useful model for financing access to physical and functional
rehabilitation in a large number of countries is probably an independently-managed
public fund. The trickiest part will be ensuring the sustainability of the fund’s resources,
and organising it in a way that is efficient and equitable, given the gaps in the supply.
The role of health insurance in financing access to physical and functional rehabilitation
should not be ignored, but it is more a medium-term prospect, given the state of the
existing compulsory and voluntary schemes in many countries and the fact that UHI
projects will necessarily give preference to organising financing for standard medical
care.
It was said that financing access to physical and functional rehabilitation will not be
enough to give the sector the means it needs to expand, and we saw that the inadequacy
of the supply had a significant impact on the cost of access. One idea to consider would
be to give a public fund a two-fold mission: first, to finance access for individuals (as was
already mentioned), and second, to implement an investment strategy for physical and
functional rehabilitation human resources, infrastructure and equipment. The advantage
of that approach would be to balance the financial effort between supply and demand
based on coherent information. While an obvious objection would be that this in some
ways violates the principle of separation between payer and providers and might favour
the busiest facilities, the supply situation seems too fragile to work only toward better
financing of demand.
In addition to these considerations, an essential recommendation with regard to
financing physical and functional rehabilitation would be to make the flow of funds that
it needs as transparent as possible.
53
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56
Understanding financial access to
physical and functional rehabilitation
services in developing countries
This report focuses on financial access
to physical and functional rehabilitation
services in developing countries, supported
by practical examples from the case of
Burkina Faso.
After some general considerations on
physical and functional rehabilitation (Part
1), which help define the scope of the study,
this report analyses the system first from
the perspective of the existing supply
(Part 2), and then from the perspective
of demand and how it is financed (Parts 3
and 4). Finally, the report looks at issues
of national disability policy and how they
relate to the possibility of changing the
system and the players who might facilitate
such change (Part 5).
The conclusion offers a variety of
recommendations on the steps that come
after the study.
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