Issue - African Health Observatory

Transcription

·
OCTOBER 2015
SPECIAL ISSUE
ISSUE 20
·
A SERIAL PUBLICATION OF THE WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR AFRICA
·
ISSN 2077 6128
THE
AFRICAN
HEALTH
MONITOR
UNIVERSAL
HEALTH
COVERAGE
REGIONAL OFFICE FOR
Africa
REGIONAL OFFICE FOR
Contents
Africa
Editorial: Universal health coverage in the African Region. . . . . . . . . . . . . . 1
The African Health Monitor
HealtH
monitor
REGIONAL OFFICE FOR
Africa
issn 2077 6128
the
AfricAn
Special issue: Universal Health Coverage
Issue 20 • October 2015
Chris Atim, Laurent Musango
1. The critical role of heath financing in progressing universal health
coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Laurent Musango, Martin Ota
2. Impact of performance-based financing on health-care quality and
utilization in urban areas of Cameroon. . . . . . . . . . . . . . . . . . . . . . . .
·
A seriAl publicAtion of the World heAlth orgAnizAtion regionAl office for AfricA
3. Institutions and structural quality of care in the Ghanaian health system. . .
4. Solidarity in community-based health insurance in Senegal:
Rhetoric or reality?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15
universal
health
coverage
© WHO-AFRO, 2015
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Africa be liable for damages arising from its use.
The contents of this publication do not necessarily reflect
official WHO views. Some papers in this publication have
not passed through formal peer review.
AFRICAN HEALTH MONITOR • OCTOBER 2015
20
Philipa Mladovsky, Pascal Ndiaye
5. Financing flows through private providers of HIV services in
sub-Saharan Africa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27
Sean Callahan, Sharon Nakhimovsky
6. Early evidence from results-based financing in rural Zimbabwe. . . . . . . .
ii
10
Eugenia Amporfu, Justice Nonvignon
·
september 2015
·
An introduction to the African Health Economics and Policy Association
and its collaboration with WHO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Omer Zang, Sebastien Djienouassi, Gaston Sorgho, Jean Claude Taptue
speciAl issue
issue 20
Matshidiso Moeti
32
Frank van de Looij, Dudzai Mureyi, Chenjerai Sisimayi, Jaap Koot, Portia Manangazira,
Nyasha Musuka
7. Piloting a performance-based financing scheme in Chad: Early results
and lessons learned. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
37
Joël Arthur Kiendrébéogo, Olivier Barthès, Matthieu Antony, Louis Rusa
8. Estimating willingness to pay for maternal health services: The Kenya
reproductive health voucher programme. . . . . . . . . . . . . . . . . . . . . . .
43
Lucy Kanya, Francis Obare, Benjamin Bellows, Brian Mdawida, Charlotte Warren,
Ian Askew
9. Fondements de la résilience et de la pérennité de la mutuelle de santé
Fandène, Sénégal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
51
Aboubakry Gollock, Slim Haddad, Pierre Fournier
10. Increasing equity among community-based health insurance members
in Rwanda. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
58
Joséphine Nyinawankunsi, Thérèse Kunda, Cédric Ndizeye, Uzaib Saya
11. L’impact des modalités d’allocation des ressources dans les mécanismes
d’exemption sur l’équité : Plan Sésame, Sénégal. . . . . . . . . . . . . . . . .
63
Maymouna Ba, Fahdi Dkhimi, Alfred Ndiaye
News and events. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
67
Abstracts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
69
Corrections to Issue 19 (March 2015)
In the article on Routine immunization in the WHO African Region: Progress, challenges and way forward (page
2): the following authors should be included: Shingai Machingaidze, Charles S Wiysonge and Gregory D Hussey
(Vaccines for Africa Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town,
Cape Town, South Africa). On page 4, the following general reference should be added: Machingaidze S, Wiysonge
CS, Hussey GD. Strengthening the Expanded Programme on Immunization in Africa: Looking beyond 2015. PLoS
Med 2013; 10(3):e1001405. doi:10.1371/journal.pmed.1001405.
Editorial
Universal health coverage in
the African Region
Complex and emerging health challenges in the African
Region, linked to rapid urbanization, globalization and public
health emergencies of international concern, have coalesced
to demand more innovative approaches to the planning and
implementation of health services in the African Region and
at country level.
Universal health coverage (UHC) aims to provide health care
and financial protection to all people in a given country with
three related objectives: equity in access – everyone who
needs health services should get them, and not simply those
who can pay for them; quality of health services – good
enough to improve the health of those receiving the services;
and financial-risk protection – ensuring that the cost of health
care does not put people at risk of financial hardship. It is a
powerful concept in public health, and one of the key areas of
progress in health in the African Region.
Universal health coverage is a powerful
concept in public health, and one of the
key areas of progress in health in the
African Region.
Universal health coverage is one of the strategic priorities of
the World Health Organization. When I addressed the 136th
Session of the WHO Executive Board in Geneva in January
2015, at the time of my appointment as Regional Director for
the African Region, I made the commitment to “work very
hard in driving progress towards equity and universal health
coverage in our Region”. This commitment is embodied in
the Africa Health Transformation Programme 2015–2020:
A vision for UHC, a strategy that will guide the work of our
Regional Office during the next five years.
Some countries in the Region are already implementing
strategies to improve access and coverage of health services,
while others have made commitments to take measures
towards UHC. As countries in the Region move towards
UHC, it is vital to understand the challenges and constraints
they are facing, identify skills shortages and capacity-building
needs, and also learn from their experiences.
This special issue of the African Health Monitor has a dual
objective: firstly, it offers an overview of research on the
subject of UHC in Africa; and secondly, it provides wider
dissemination of research results presented and discussed
in African scientific meetings. All the articles of this special
issue originated from presentations made during the African
Health Economics and Policy Association (AfHEA) 3rd biennial
scientific conference held in Nairobi in March 2014. Eleven of
the 188 presentations made at the conference were selected
by a joint team of WHO staff and AfHEA members and
expanded into full papers for publication in the Monitor. With
their focus on UHC, they cover themes such as performancebased financing, equity and quality of care, communitybased health insurance and health vouchers, and the impact
of allocation of resources in the context of exemption. The
articles also describe the achievements and challenges
countries face when implementing reforms and introducing
policies and strategies towards UHC.
Universal health coverage in the African Region – the subject
of this special issue of the Monitor – is a high priority and I
call on all policy-makers, researchers, academics and health
workers to read this issue and provide suggestions for future
work in support of UHC in the Region. I take this opportunity
to encourage Member States to implement, monitor and
evaluate the progress of UHC in their respective countries,
as well as to conduct research to provide evidence and
disseminate best practice. Finally, I commend the AfHEA for
their initiative in organizing their biennial scientific conference
and would encourage WHO partners to provide support to
the AfHEA and other African health associations fostering
research in public health in the Region.
Dr Matshidiso Moeti
WHO Regional Director for Africa
ISSUE 20 • SPECIAL ISSUE ON UNIVERSAL HEALTH COVERAGE
1
An introduction to the African Health
Economics and Policy Association
and its collaboration with WHO
Chris Atim,i Laurent Musangoii
Corresponding author: Laurent Musango, e-mail: [email protected]
T
he African Health Economics and
Policy Association (AfHEA) is
a bilingual (English and French)
apolitical and not-for-profit association
launched in Accra, Ghana, in March 2009,
where its headquarters are located. The
overall mission of AfHEA is to contribute
to the promotion and strengthening of
the use of health economics and health
policy analysis to achieve equitable and
efficient health systems and improved
health outcomes in Africa, especially for
the most vulnerable populations. AfHEA
has more than 200 members from African
countries working in the health economics,
health financing and health policy fields.
One of the key mandates of AfHEA is
to build the capacity of young researchers
in its main focus areas. And this capacity
building is an area in which the WHO
African Region has been a key partner.
AfHEA holds a scientific conference
every two years. Since its inception in
2009, AfHEA has held three scientific
conferences; in Ghana (2009), Senegal
(2011) and Kenya (2014). AfHEA’s
conferences bring together both
young and established researchers and
professionals working in its key theme
areas from Africa and across the globe
to share knowledge, identify existing
research gaps and network.
The most recent scientific conference, in
March 2014 in Nairobi, Kenya, had the
theme “The Post-2015 African Health
Agenda and UHC: Opportunities and
Challenges.” This theme was influenced
by the WHO 2010 World Health Report –
Health Systems Financing: The path to universal
coverage which called upon countries to
move towards universal health coverage
(UHC). However, moving towards
UHC requires technical capacity, which
is lacking in a majority of African
countries. In 2012–2013, AfHEA, in
collaboration with the WHO African
Region, implemented a survey that sought
to find out what countries in Africa are
doing in the area of UHC; useful lessons
that have been learnt by countries and
which can be shared with other countries
designing and implementing similar
policies and programmes; the challenges
and constraints countries are facing; and
the critical areas of capacity development,
skills shortages and requirements that
need to be addressed.
The 2014 conference attracted around
260 participants from 42 countries from
Africa and beyond. This was a 15%
increase in attendance from the 2011
conference held in Saly, Senegal. Of the
260 participants, just over a third were
female. The participants were drawn
from different types of organizations and
institutions including: academic, research,
ministries of health, government agencies,
development partners and others.
The main objectives of the third AfHEA
conference were to:
Actively define the research agenda and
identify successes and research gaps
regarding UHC in Africa post-2015;
Ensure a minimum of 30 African
countries and 200 participants
from Africa (both francophone and
anglophone) attend the conference;
Ensure attendance from at least 15
globally recognized experts on African
health economics and policy;
Present at least 80 abstracts;
Publish all abstracts and posters of
the conference both in hard copy and
electronically; and
i African Health Economics and Policy Association
ii Regional Adviser for Health Financing and Social Protection, WHO Regional Office for Africa, Brazzaville, Congo
2
Translate outputs from the AfHEA
conference into policy notes to
disseminate to decision makers.
And the overarching goals of the
conference (as with previous ones) were
to:
Provide an opportunity for policy
makers, development partners and
researchers to interact on the theme
of the conference;
Build the capacities of younger
researchers who would be able
to interact with senior and more
experienced colleagues and obtain
feedback and mentorship on abstracts
and presentations; and
Contribute to infor ming and
developing health financing policy in
Africa.
Following the conference, AfHEA
has collaborated with WHO-AFRO to
publish 11 of the papers presented at
the conference in this special issue of
WHO’s African Health Monitor. The aim
of this activity has been to further build
the capacity of the authors in writing
and publishing high-quality research
papers. The authors of the selected
papers received technical guidance
and support from AfHEA and WHOAFRO’s established researchers to ensure
that the papers were of high quality and
met WHO standards. WHO-AFRO
also wishes to acknowledge the financial
support provided by DFID for the
preparation of this publication.
The fruitful collaboration between AfHEA
and WHO-AFRO will continue in future
as both organizations work together to find
local solutions to the unique challenges
facing Africa’s health sector. p
e
The critical role of health
financing in progressing
universal health
coverage
Laurent Musango,i Martin Otaii
Corresponding author: Laurent Musango, e-mail: [email protected]
U
niversal health coverage has been
defined as the ability of all people
who need health services to
receive them without incurring financial
hardship, thereby achieving equity in
access.1 Universal health coverage consists
of two interrelated components:
Coverage with quality health
ser vices, including promotion,
prevention, treatment, rehabilitation
and palliation;1 and
Coverage with financial protection,
for everyone.2
aims to ensure that they do not suffer
financial hardship linked to paying for
these services.
The former captures the aspiration that
all people should obtain the good quality
health services they need, while the latter
Progressing towards the goal of UHC
requires countries to advance in terms of
health system inputs, outputs and coverage
For all countries, moving towards UHC
is a process of progressive realization
on several fronts: the range of available
services; health services of sufficient
quality to achieve the desired outcomes;
the proportion of costs of those services
covered; and the proportion of the
population covered with specific focus
on equity.3
SUMMARY—It is clear that health financing is
central to providing the different components of
health systems vital to making progress in the
implementation of universal health coverage
(UHC). However, there are several constraints on
health financing systems throughout the African
Region which are impeding this progress. These
include: insufficient financial resources; heavy
reliance on out-of-pocket health expenditure;
inefficiency in management of health systems;
levels of governance and accountability;
harnessing stakeholder contributions in
health financing; and weak research, including
monitoring and evaluation. Progress is being
made on the last issue with the rolling out of
the revised System of Health Accounts 2011. The
article concludes with a list of the Region’s key
requirements which would facilitate strengthening
health financing and thus improve UHC.
Voir page 69 pour le résumé en version française.
Ver a página 69 para o sumário em versão portuguese.
i Regional Adviser for Health Financing and Social Protection, WHO Regional Office for Africa, Brazzaville, Congo
ii Regional Adviser for Research and Publication
3
Figure 1. Total health expenditure (THE) on health per capita, 2012
1 200
1 138
1 000
800
US$
645
600
384 397
400
444
473
521
259 279
200
138 144
Eritrea
Democratic Republic of the Congo
Ethiopia
Central African Republic
Madagascar
Burundi
Malawi
Niger
Gambia
Guinea-Bissau
Chad
Guinea
Benin
Mozambique
Comoros
Burkina Faso
Togo
United Republic of Tanzania
Mali
Uganda
Kenya
Senegal
Mauritania
Cameroon
Liberia
Rwanda
Ghana
Côte d’Ivoire
Nigeria
Sierra Leone
Zambia
Congo
Sao Tome and Principe
Lesotho
Cape Verde
Angola
Swaziland
Algeria
Botswana
Gabon
Mauritius
Namibia
Seychelles
South Africa
Equatorial Guinea
0
109
83 88 94 96 96 100
45 51 52 59 65 66
15 15 18 18 18 20 25 25 26 30 31 32 33 37 38 38 41 41 42 44
190
of good quality services in all population
groups while ensuring solidarity through
financial protection against catastrophic
OOP health payments. It is necessary
to pool resources and to eliminate direct
payments at the point of service in order
to provide quality services equitably.
UHC is much desired and progress in its
implementation will result in improving
health outcomes and tackling poverty,
by increasing access to, and coverage of,
quality health services, and by reducing
the suffering associated with payment for
health services. Health financing is central
to providing the different components of
health systems needed to make progress
in UHC. However, there are several
constraints militating against the financial
resources for health that are essential to
implementation of UHC in the African
Region.4,5 This article describes those
constraints and potential measures to
circumvent those challenges.
Constraints in
implementation of
universal health
coverage
Insufficient financial resources
The high-level Taskforce on Innovative
International Financing for Health
Systems6 estimated that in 2009 a low4
income country needed to spend on
average US$ 44 per capita, and US$ 60
as a target for 2015, to strengthen its
health system and to provide an essential
package of health services. In 2012 the
data show that 26 countries were on or
above US$44 per capita while 19 were
below that amount (Figure 1).
Unexpectedly, there is no positive
correlation between health expenditure
and health indicators – r²=0.17 for the
maternal mortality rate (MMR) and 0.018
for the under-five mortality rate (U5MR).
In addition, the countries with an average
expenditure on health of more than US$
60 per capita do not have improved health
indicators; probably due to inefficiency in
the utilization of the available resources
including the prioritization of highimpact interventions. For example,
Mauritania, Côte d’Ivoire and Sierra
Leone are spending US$ 50–100 per
capita on health, but their MMRs are
300, 700 and 1 100 per 100 000 live births,
respectively. Algeria, Botswana and South
Africa have low rates of MMR, <200
deaths per 100 000 live births, but they are
spending respectively US$ 250, 380 and
650 per capita. This situation is similar
for the U5MR (Figure 2). Spending in
investment and supply will not show
outcome impact (reduction of mortality
and morbidity), but investing in primary
health care and high-impact interventions
may show a quick outcome impact.
Apart from per capita expenditure,
governments can also allocate more money
for health from domestic sources. In this
regard, the 2001 Abuja Declaration urges
African Union states to allocate “at least
15%” of national budgets to the health
sector”. Despite this landmark decision,
only six countries had implemented this
by 2012 (Liberia, Rwanda, Swaziland,
Zambia, Malawi and Togo). Considering
both the Abuja and high-level Task Force
targets, only Liberia, Rwanda Swaziland
and Zambia have met both (Table 1).
Heavy reliance on out-ofpocket health expenditure
The public health facilities rely heavily
on funds obtained through prepayment
schemes and OOP spending of patients
as a source of health-care financing to
meet operational costs. Evidence shows
that when OOP payments are below
20% as a proportion of THE, the
incidence of financial catastrophe caused
by OOP health expenses is negligible.
However, this was not the case for 35
countries (79%) of the 47 countries in
the African Region in 2012 where OOP
expenditure was more than 20% of THE.
Indeed, in 21 (45%) countries, the OOP
was more than 40% of THE, which
presumes that households are exposed
to impoverishment caused by catastrophic
health expenditure (Figure 3).
Figure 2. Total health expenditure (THE) per capita versus MMR and
U5MR in the African Region, 2012
R-Squared=0,302063
1100
Sierra Leone
Table 1. Total health expenditure
against general government health
expenditure (GGHE)/general
government expenditure (GGE),
2012
GGHE/GGE >15%
1000
Liberia, Rwanda,
Swaziland, Zambia
(4 countries)
900
800
MMR in 2013
700
Côte d'Ivoire
Malawi, Togo
(2 countries)
500
Angola
400
300
Swaziland
Equatorial Guinea
Zambia
200
Gabon
Botswana
Namibia
100
Algeria
Cabo Verde Republic of
0
0
100
200
300
South Africa
Mauritius
400
500
600
700
800
900
1000
1100
1200
THE/per capita in USD in 2012
R-Squared=0,133105
170
Angola
160
Sierra Leone
150
Chad
130
120
Nigeria
U5MR in 2013
110
100
Lesotho
90
80
Equatorial Guinea
Swaziland
70
60
Algeria, Angola, Botswana,
Cape Verde, Congo, Côte
d’Ivoire, Equatorial Guinea,
Gabon, Ghana, Lesotho, Mali,
Mauritius, Namibia, Nigeria,
Sao Tome and Principe,
Seychelles, Sierra Leone,
South Africa
(18 countries)
THE per capita <US$ 60
600
140
GGHE/GGE <15%
THE per capita >US$ 60
Chad
Ethiopia
Benin, Burkina Faso, Burundi,
Central Africa Republic,
Cameroon, Chad, Comoros,
Democratic Republic of the
Congo, Eritrea, Ethiopia,
Gambia, Guinea, Guinea
Bissau, Kenya, Madagascar,
Mauritania, Mozambique,
Niger, Senegal, Uganda, United
Republic of Tanzania
(21 countries)
The incidence and intensity of
catastrophic health expenditure and
impoverishment due to health payments
are shown in Figure 4. A recent survey
on financial protection in seven African
countries showed that the incidence of
catastrophic health expenditure ranged
from 6.8% in Mauritania to 0.42 in
Seychelles. Impoverishment due to health
payments was highest (2.7%) in Kenya
and lowest (0.15%) in South Africa.7–12
It is very clear that the burden of OOP
payments is high in the African Region,
and households are becoming poor and
many more are being trapped in poverty
due to health-care payments. African
Members States should urgently consider
alternative health financing mechanisms
that offer financial risk protection to the
population. Such approaches, as clearly
stated in the WHO 2010 report, should
encourage risk pooling and income crosssubsidization.1
Gabon
50
Namibia
Botswana
Congo
40
Some African countries are doing
relatively well in the implementation of
the WHO 2010 recommendations and
five of the best practices documented13
are described in Table 2.
South Africa
30
Algeria
20
Mauritius
10
0
0
100
200
300
400
500
600
700
800
THE/per capita in USD in 2012
900
1000
1100
1200
Inefficiency in management
of health systems
Implementation of pre payment
mechanisms will not have much positive
impact if not executed simultaneously
5
Figure 3. Out-of-pocket expenditure as percentage of THE, 2012
90
76
61
56
53
53
53
52
50
49
48
47
46
44
44
44
43
41
41
41
40
36
34
34
32
32
31
30
29
28
27
25
24
20
21
21
21
16
15
15
13
10
Figure 4. Distribution of households facing catastrophic health expenditure
payments and impoverishment due to capacity to pay in seven countries of
Africa
Catastrophic health expenditure
Impoverishment due to health payment
8
7
6.96
Percentage (%)
6
5
4.60
4
4.00
3
2
1
4.54
2.70
2.30
1.54
2.59
1.78
1.72
0.50
0
Mauritania
Kenya
Burkina
Faso
Côte
d’Ivoire
with efficiency measures. Improving
provider performance and contracting in
service delivery have not been optimally
explored to ascertain whether they offer
efficiency savings. The capacity required
to design and implement them is lacking.
The legal and regulatory frameworks are
inadequately reinforced and as a result
inappropriate procurement, irrational use
of medicines, inappropriate staff mix
6
Senegal
0.15
South
Africa
0.42 0.32
Seychelles
and deployment, coupled with a lack of
performance incentives, are not uncommon.
There are also weak policies related to
allocation and timely disbursement of funds
to end users. This may lead to overuse
and overfunding of certain health services
and avoidable wastages especially due to
pilferage. WHO estimates that globally,
20–40% of all health spending is wasted
through inefficiency.1
South Africa
Malawi
Algeria
Lesotho
Gambia
Rwanda
Liberia
Cape Verde
Congo
Zambia
Angola
Ghana
Burundi
Madagascar
Senegal
Mauritania
Togo
Burkina Faso
Gabon
Ethiopia
Guinea-Bissau
Equatorial Guinea
Benin
Comoros
Kenya
Mauritius
Uganda
Chad
Eritrea
Niger
Mali
Côte d’Ivoire
Cameroon
Guinea
Nigeria
7
Sierra Leone
0
11
7
6
5
2
Seychelles
63
60
Mozambique
66
Namibia
67
Botswana
70
Swaziland
80
Governance and
accountability
African leaders are taking the decision to
implement UHC. Some countries in the
African Region are already implementing
strategies to improve access to and
coverage of health services (Botswana,
Gabon, Ghana and Rwanda) while many
others (Benin, Burundi, Congo, Côte
d’Ivoire, Democratic Republic of the
Congo, Kenya, Malawi, Mali, Mauritius,
Namibia, Nigeria, Senegal, Seychelles,
Sierra Leone, Togo, Uganda and United
Republic of Tanzania) have made
commitments to take measures towards
achieving UHC.
However, implementation of UHC requires
putting in place a clear policy and plan
with a monitoring and evaluation (M&E)
framework to guide the implementation
and to measure progress. It also calls for
government stewardship to coordinate
the different stakeholders. Although
mobilizing sufficient financial resources
and obtaining long-term commitments
are obviously crucial requirements, design
details, the formulation process, and
implementation plans also need careful
consideration.
Table 2. Best practice in the
implementation of UHC: What works
in the African Region
GHANA
Ghana has been implementing health financing
reforms since 2004 in order to increase population
coverage with prepayment pooled mechanisms,
reduce direct OOP payments and increase the range
of services provided in the benefit package. The
Ghana National Health Insurance Scheme (NHIS)
is one of the most comprehensive schemes to be
established in sub-Saharan Africa. Under the scheme,
exemptions for the poor were included initially.
Indeed, relatively poor districts and disadvantaged
population groups have higher NHIS coverage. The
key design principles are “equity” in access to a
defined benefit package irrespective of the capacity
to pay and “risk equalization” where the financial risk
of illness is equally shared among all.
RWANDA
Rwanda has enacted a law regarding the creation,
organization, operation and management of a national
health insurance scheme. The law stipulates that,
“Any person residing in Rwanda shall be bound to
health insurance, any foreigner entering the country
shall be also be bound to health insurance within a
time limit not exceeding fifteen days.” The scheme
now covers about 92% of the population and finances
medical consumables, services, capital projects,
logistics and equipment for service providers. In
addition, a strategy to identify destitute people in
order to determine national health insurance scheme
contribution subsidies and exemptions has been
devised, and the government and development
partners pay for groups that have been identified as
part of poverty alleviation activities.
GABON
Gabon initiated reforms in 2007 in its health financing
system to achieve UHC. The reform culminated in
the establishment of the National Health and Social
Insurance Fund, which receives money through
special taxes paid by mobile telephone and money
transfer companies, and social contributions by wage
earners, independent workers, employers and state
subventions. The authorities adopted an incremental
approach to membership, starting in 2008 with the
poorest, state employees in 2010 and private sector
workers in 2013. The Caissse Nationale d’Assurance
Maladie et de Securité Sociale (CNAMGS) resources
for health have multiplied by four in three years,
from about 10 billion CFA francs in 2008 to more than
37 billion CFA francs in 2011. The pooling of funds
has facilitated access to health services for various
categories of the population such as the formal and
informal sector, and both rich and poor.
Harnessing stakeholder
contributions in health
financing
The health arena in the African Region
contains many actors, dispersed efforts
and unclear results in relation to impact
on priority health problems. Most
health systems in the African Region are
pluralistic; services are delivered by public
and non-state providers, including private
for-profit and private not-for-profit actors.
Communities also play a role in mobilizing
resources for health and service delivery.
In addition, improving health outcomes
requires the effort of more than the health
sector alone. Harnessing the contribution
of the multiplicity of actors remains a
challenge due to lack of implementation of
appropriate frameworks and instruments.
Roles and mandates of the different
stakeholders are not explicitly spelt out.
In addition, the capacity of government
officials in negotiation, comprehensive
planning and monitoring needs to be
strengthened.
Research including
monitoring and evaluation
Monitoring and operational research
systems are still weak, making it hard
to evaluate achievement, identify gaps
and implement appropriate solutions
to make progress. Although several
countries have undertaken national
health accounts (NHA) to inform policy
making and guide priority setting when
developing national health strategies
and operational plans, it is not yet
institutionalized in several countries. As
countries move forward, they will need
to track their own progress and make
adjustments to their strategies and plans
on health financing as necessary. Some
progress has been made in the Region in
recent years – 33 countries participated
in orientation and capacity-building
workshops for the revised System of
Health Accounts (SHA) in 2011. As a
result 60% of those countries are using
(or preparing to use) SHA, which is the
global standard for tracking resources,
adopted by various UN agencies such
as UNAIDS and UNFPA, as well as by
the Global Fund for AIDS, Tuberculosis
and Malaria. This means that they are
producing health accounts with disease
expenditures including expenditures on
women’s, children’s and adolescents’
health. They are also in the process of
institutionalizing SHA so that accounts
are produced annually for expenditure of
the previous year, with results published
on time for budget development and
policy planning.
BURUNDI
Burundi, faced with challenges of underfunding,
implementation of user-fee schemes with subsequent
impoverishment, low utilization of services that
were of poor quality, and poor health indicators,
the government introduced fee exemptions for
pregnant women and children under five in 2006.
Although this led to a marked increase in health
service utilization, the persistent underfunding for
health by the government further compromised the
quality of health services, with disgruntled health
workers and subsequently reduced utilization rates.
Official user fees were replaced by under-the-table
payments. Piloting of results-based financing (RBF),
a health financing strategy that focuses funding to
outputs, was introduced in 2008. The health facilities
in the pilots received performance bonuses for both
the quantity and quality of services delivered, and
quantity indicators related to a basic health package,
which included services that were exempted from the
fee scheme. The pilots produced positive results with
an average increase of 50–60% for each indicator
compared with the period before the introduction of
RBF. This initiative was scaled up to more provinces
and a national RBF scheme was launched.
BOTSWANA
Botswana is one of the few countries in the Region to
make a significant government investment in health.
The current health financing system provides a high
level of financial risk protection for its population
compared with other countries in the Region.
Botswana uses a tax-based system to cover the
population for a wide range of services, and has one
of the Region’s lowest levels of OOP spending on
health at only 8% of THE. Government expenditure
on health, at US$ 384 per capita, is also considerably
higher than the average (US$ 147 per capita) for other
countries in the Region.
Source: The African Regional Health Report, 201413
7
Figure 5. Sources of funding allocated to health in the African Region, 2012
Spending by households (%)
Expenditure by government (%)
Other/partners (%)
100
80
60
40
To date, 11 countries are producing
or have already produced at least two
consecutive SHA 2011 health accounts
reports with disease expenditures.
Another 10 countries are in the process
of producing their first SHA 2011
with disease expenditures, including
expenditure on women’s, children’s and
adolescents’ health (Figure 6).
To show how UHC is making progress, in
addition to the NHA mentioned above,
the use of the framework of monitoring
progress towards UHC at country and
global levels, elaborated and published
jointly by WHO and the World Bank, will
be useful in measuring progress at country
and regional level. Baseline studies using
this framework to assess capacity to
successfully apply the framework for
monitoring progress towards UHC have
already been conducted for Ethiopia,
Ghana, Kenya, South Africa and the
United Republic of Tanzania. Botswana,
Côte d’Ivoire, Lesotho, Namibia,
Uganda, Seychelles and Swaziland are in
the process of producing their baseline
assessments on progress towards UHC
using the same framework.14,15
8
Guinea
Sierra Leone
Nigeria
Mali
Cameroon
South Sudan
Niger
Côte d’Ivoire
Chad
Eritrea
Kenya
Uganda
Mauritius
Central African
Equatorial Guinea
Benin
Comoros
Togo
Guinea-Bissau
Gabon
Ethiopia
Senegal
Burkina Faso
Mauritania
Ghana
Madagascar
Burundi
Congo
Angola
Zambia
Liberia
Rwanda
Gambia
Cape Verde
Algeria
Lesotho
Malawi
Swaziland
Namibia
South Africa
Botswana
Seychelles
0
Mozambique
20
Figure 6. Countries’ progress in institutionalizing national health accounts in
the African Region, May 2015
Cabo Verde
Comoros
Mauritius
Sao Tome and
Principe
Seychelles
Key requirements for
strengthening health
financing to improve UHC
Support for assessing the current
situation in relation to health
financing and UHC: financial and
technical support to country teams
analysing the current state of UHC,
how the health financing system
currently operates, and technical
options for change that would enable
progress towards UHC.
Facilitate inclusive policy dialogue
for health financing strategy
development: Development or
revision of countries’ policies and
strategies for health financing systems
will ideally involve multistakeholders –
all ministries involved in the provision
or financing of health services
(including the ministries of finance,
labour and social affairs), subnational
governments, civil society, private
sector etc. Existing platforms should
be used wherever they operate well
– for example, active donor groups
often exist at country level (sometimes
separately for health financing issues)
and could be used as the facilitation
mechanism; regional partnerships
such as Harmonization for Health in
Africa (HHA) could facilitate these
exchanges in some countries; while
global partnerships such as Providing
for Health (P4H) would be able to
encourage these country dialogues in
other settings. In addition, WHO will
facilitate dialogue and interaction with
the national health planning process
where this is occurring.
Scale-up policy advice to countries:
This should occur during the
evaluation of health financing options,
and then in the provision of technical
support during the rollout of plans
and strategies, and the monitoring
and feedback stages. Again, existing
partnerships would be used where they
work well and have the expertise in
health financing for UHC.
Facilitate innovation and learningby-doing at country level: It is
important that countries are able to
innovate, monitor and evaluate as
they move forward so that they can
modify their own strategies rapidly
when necessary. Other countries
could also benefit from sharing
experiences. Innovation with learningby-doing is required in almost all of
the specific health financing reforms
that might be instituted – linked to
raising more money, reducing financial
barriers and increasing financial risk
protection, and improving efficiency
and equity. External partners as
well as governments would need to
provide sufficient finance to rollout
innovations, but also to fund recipientcountry nationals or institutions to
undertake independent reviews of
achievements. They would also need
to provide technical inputs on design
and implementation of this type of
“research” in some settings.
Provide support to countries
seeking to improve transparency
and accountability: It is important
to assess the way health funds are
raised and used. This would require
among other things strengthening the
country’s ability to: a) track financial
resources allocated to and spent on
health, including government, nongovernment and external resources
(institutionalized in the NHAs); b)
identify how resources are used and
who benefits from them; and c)
identify areas in which more “value
for money” could be obtained by
improving efficiency and equity.
Conclusion
UHC is obviously an ambitious endeavour
but making progress on it will be of
immense benefit, particularly to the
African Region as it will be associated
with improved access to health services,
financial protection to all citizens of a
particular country and improved health
outcomes. The development of robust
health financing policies, strategies and
sustainable financing mechanisms are
central to the implementation of the key
components of UHC. These strategies
will require that the various sectors and
stakeholders within and outside the health
sector play their roles. Countries need to
take responsibility, ownership and lead the
processes involved. WHO will convene the
necessary forums and provide the technical
support to facilitate the acceleration of the
processes needed for UHC. p
References
1. World Health Organization. The World Health Report 2010:
Health systems financing – the path to universal coverage.
Geneva: World Health Organization 2010. Available:
http://www.who.int/whr/previous/en/ [accessed 19 June
2015].
2. Boerma T et al. Monitoring Progress towards Universal
Health Coverage at Country and Global Levels. PLoS Med
2014; 11(9).
3. Rodney AM, Hill PS. Achieving equity within universal
health coverage: a narrative review of progress and
resources for measuring success. Int J Equity Health 2014;
13:72.
4. WHO. Universal health coverage (UHC) in the African Region.
Technical report prepared for the joint meeting of the
ministers of finance and ministers of health of Africa,
Tunis. Regional Office for Africa, Brazzaville, Congo: World
Health Organization 2012.
5. WHO. State of health financing in the African Region.
Regional Office for Africa, Brazzaville, Congo: World
Health Organization 2013.
6. Taskforce on Innovative International Financing for Health
Systems. More money for health, and more health for
the money; to achieve the health MDGs, to save the lives
of millions of women and children, and to help babies
in low-income settings have a safer start to life. London
2009.
7. Khatry MMO et al. Rapport sur les dépenses
catastrophiques et l’impact des paiements directs sur
l’appauvrissement des ménages : Cas de la Mauritanie. Afr
Health Mon 2013; 17:41–45.
8. Chuma J, Maina T. Catastrophic health care spending
and impoverishment in Kenya. BMC Health Serv Res 2012;
12:413. 1 1
9. Doamba JEO et al. Dépenses catastrophiques de santé
et leur impact sur l’appauvrissement des ménages et
l’utilisation des services de santé : Cas du Burkina Faso. Afr
Health Mon 2013; 17:36–40.
10. Sow M et al. Rapport d’analyse sur les dépenses
catastrophiques de santé et leur impact sur
l’appauvrissement et l’utilisation des services au Sénégal,
2005 et 2011. Afr Health Mon 2013; 17:46–50.
11. Koch SF. Out-of-Pocket Payments on Health: The 2005–06
and 2010–11 South African Income and Expenditure
Surveys. Technical report, WHO Country Office 2015.
12. Justine HSU. Financial protection from catastrophic and
impoverishing health payments in Seychelles. Technical
report, WHO Country Office 2015.
13. WHO. The African Regional Health Report: The health of the
people, what works? Regional Office for Africa, Brazzaville,
Congo: World Health Organization 2014.
14. World Health Organization. National Health Account
database: http://apps.who.int/nha/database/Select/
Indicators/en [accessed 19 June 2015].
15. WHO and the World Bank Group. Monitoring progress
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levels: Framework, measures and targets. Geneva: World
Health Organization; 2014. Available: http://www.who.
int/healthinfo/universal_health_coverage/en/ [accessed
19 June 2015].
9
2
Impact of performancebased financing on
health-care quality and
utilization in urban areas
of Cameroon
Omer Zang,i Sebastien Djienouassi,i Gaston Sorgho,i Jean Claude Taptueii
Corresponding author: Omer Zang, e-mail: [email protected]
P
erformance-based financing has
attracted considerable interest
from governments and aid
agencies in low-income countries as a
means to increase productivity and quality
of health-care providers. Supply-side PBF
is an instrument that links financing to
pre-determined results, with payment
made upon verification that the agreed
results have actually been delivered by
the health facility. In Africa alone, more
than 35 countries, including Cameroon,
are implementing or are in the process of
introducing payment methods that reward
performance.1 Many impact studies, with
varying degrees of rigour, have been or
are being carried out in various settings on
SUMMARY—This article looks at a pilot project
designed to estimate the impact of performancebased financing (PBF) on the quality and
utilization of health care in a predominantly urban
setting – the Littoral region of Cameroon. It uses
three quasi-experimental impact evaluation
methods involving matching and differencein-difference. Results show that the PBF pilot
had a positive and significant impact on most
essential aspects of quality of care. Meanwhile,
there was no impact on any of the indicators
of health service utilization with the exception
(limited) of modern contraceptive methods. These
findings suggest that the setting and indicators
chosen are important in achieving maximum
impact. However, it should also be noted that
improvements in utilization might be limited as a
result of high baseline figures. Finally, the findings
show that the quality of care seems to be the most
promising aspect in terms of improvements related
to PBF in urban settings.
10
i World Bank
ii Ministry of Health, Cameroon
PBF and other similar financial incentives
aimed at health workers. Randomized
experiments were carried out in order
to monitor health worker attendance in
India and incentivized service quality
by physicians in the Philippines. Results
showed that in India, the monitoring
system was initially extremely effective but
became ineffective after 18 months due to
administration laxity. In the Philippines,
service quality-based incentives had
significant effects.2,3
In Africa, to date, only two experimental
studies of the impact of PBF on health
service provision and utilization have
been completed, in Rwanda and the
Democratic Republic of the Congo. In
Rwanda, PBF proved an efficient way
to increase health service quality and
utilization, resulting in improved child
health outcomes.4,5 In the Democratic
Republic of the Congo, Elise Huillery et
al (2013) found that financial incentives
improved effort from health workers
to increase targeted service provision,
but demand for health services was not
responsive to these incentives.6 Most other
studies using non-credible comparison
groups or comparing simple before and
after situations advocate PBF as a way
to increase accountability, efficiency,
quality and quantity of service delivery.7–14
Loevinsohn and Harding (2005) reviewed
ten studies on the effect of contracting
with non-state entities, including nongovernmental organizations (NGOs), as
a way to improve health-care delivery,
and concluded that contracting for the
delivery of primary care can be very
effective and that improvements can be
rapid.15
Given the rising popularity of this
financing strategy, robust evidence about
its effects is still needed.16,17 One way of
improving the robustness of the evidence
might be, when an experimental design
was not prepared, the use of multiple
quasi-experimental methods to assess
the impact.18
Cameroon has made little progress
towards achieving the Millennium
Development Goals (MDGs). In
fact, with a few exceptions such as
immunization, most key indicators of
maternal and child health and nutrition
have stagnated or worsened since 1990.
The mortality rate in under-five-year-olds
rose in Cameroon in the 1990s and has
stagnated in the 2000s. Maternal mortality
has remained high and even worsened
since 1998. 19 Analysis of the health
system of Cameroon indicates that linking
performance to results could indeed
make a difference. The PBF programme
in Cameroon also includes enhanced
supervision as well as financial and hiring
autonomy on PBF subsidies.20 It is clear
in Cameroon, suboptimal allocation of
resources and resource use inefficiencies
are key underlying determinants of
the limited improvements achieved in
the health sector. An important part
of the problem is that the operational
level receives a small fraction of the
health budget while the lion’s share of
resources is allocated for administration.20
Inefficiencies are also created by the
inadequate alignment between the burden
of disease in Cameroon and health
expenditures. Governance problems are
at the root of the second key constraint
to district health system functioning
in Cameroon. 20 Furthermore, nontransparent human resource management
practices combined with low salary levels
drive health workers to abuse public
funds by charging informal payments
or over-billing patients for services and,
ultimately, deter use by the poor. 20,21
Finally, cost recovery mechanisms are
extensively used in Cameroon, and are
the greatest source of revenue for health
facilities.7,21,22
The objective of the study reported in this
article is to estimate the impact of a PBF
pilot project on quality and utilization
of health care in an urban setting and
cross-check the results with various quasiexperimental impact evaluation methods.
Method
Within the framework of the quasiexperimental impact evaluation study of
Cameroon’s PBF project in the Littoral
region, a baseline survey was conducted
in January 2011 and follow-up survey in
February 2013. Three quasi-experimental
impact evaluation methods were applied
for this study.
Study area
Cameroon is a central African country
with a population of almost 22 million
as estimated in 2014. Cameroon’s health
system is organized into 10 regions, 189
health districts and around 1 700 health
areas. As assessed in 2012 by its Ministry
of Health, the country has 1 888 public
integrated health centres, 760 private
health centres, 155 sub-divisional health
centres and 164 district hospitals. Overall,
the health system of Cameroon is staffed
with 1 842 medical doctors, 18 954 nurses
and 1 340 pharmaceutical personnel.20
In 2011, per capita total health
expenditure was US$ 61. Private spending
(out-of-pocket) accounted for 51.4% of
total expenditure on health, while public
spending accounted for 33% and external
resources for 14.4%. The share of private
pre-payment is very low at 1.2% of
total health expenditure. Government
expenditure on health is low (US$ 328.2
million), amounting to 6.2% of total
government expenditure in 2011.20
The 2011 Demographic and Health
Survey – Multiple Indicator Cluster
Survey (DHS-MICS) survey estimated
that 53% of children aged 12–23 months
were fully immunized. Despite a high level
of awareness, 23% of women aged 15 to
49 years who are in a relationship use
some form of contraception. In the same
year, 85% of pregnant women consulted
a skilled health care provider during their
pregnancy. Moreover, close to 40% of
women were still giving birth at home
in Cameroon. For all these indicators,
urban/rural and interregional disparities
are very large.19,20
Littoral is the most developed region
of Cameroon and hosts the country’s
economic capital. With a population of
2.8 million it is the third most peopled
region of the country. The region accounts
for 3 701 health personnel; almost 18%
of national health human resources for
12% of the country’s population. The
health map of the region, made up of
19 health districts, 163 health areas and
around 310 primary and secondary level
health facilities, suggests that, overall,
the setting of the PBF pilot project is
mostly urban. The intervention targets
four treatment health districts, home to
636 000 inhabitants.22
The same sampling design was applied
for both the baseline and endline surveys,
hereafter designated as PBF-LT surveys.
The four health districts of the treated area
are: Cité des Palmiers, Edea, Loum and
Yabassi. The six control health districts
are: Nylon, Mbanga, Melong, Logbaba,
Nkongsamba and Manjo. For the purpose
of delimiting comparable health zones
for the project and the evaluation, these
health districts were disaggregated into
152 health zones among which 40 were
randomly sampled for the baseline survey
and then revisited in the endline survey.
In the rest of this article, they will be
designated as delimited health zones.
A total of 52 private and public health
facilities were numbered in those delimited
health zones and the household survey
randomly targeted 1 000 households; 25
per delimited health zone.
11
Power calculations were conducted
assuming antenatal care and full
immunization coverage as results of
interest to assess the validity of the overall
sample size. They concluded that for a
level of power of 80–90%, a sample size
of 1 000 households was enough to allow
any impact on utilization to be detected.
Power calculations were not conducted
for health facilities sampling.
Table 1 shows the sample sizes of baseline
and endline surveys. Among 1 000
households surveyed, 62.5% were located
in urban areas. Out of the 40 sampled
delimited health zones investigated, 25
were urban.
Three questionnaires were designed
for the PBF-LT surveys and served as
guidelines for households and main health
facilities of delimited health zones data
collection. The household questionnaire
collected data on the household
composition; some characteristics
of under-five-year-old children; some
household characteristics – including their
assets, income and expenses, sickness
episodes; under-one-year-old children
immunization; characteristics of the
latest pregnancy of the household; and
attitudes of women of reproductive
age to contraception. The health facility
questionnaire focused on health facility
identification; catchment area population
size; facility expenses and income; and
personnel payment. A health facility
quality checklist served to collect quality
scores on the following components:
structural quality; outpatient care;
maternity; family planning; vaccination
and antenatal care protocols; laboratory;
and drug and supply availability (safety
stock measured by the monthly average
consumption). Each component of the
quality checklist had a maximum score
ranging from 3 to 12 points and included
a series of items that “quality verifiers”
should observe during the survey.
The overall quality score summed up
all component scores included in the
checklist for a given facility. The maximum
value was 68 points (see Table 3).
Cameroon’s National Committee on
Ethics and Human Health provided
ethical clearance for all the surveys related
to the process of impact evaluation of the
PFB on health in Cameroon.
Impact evaluation quasiexperimental methods
The study used the propensity score
matching method technique (PSM),
the double difference or difference-indifference method (DD) and a mix of
these two methods as a third impact
evaluation approach.
The basic idea behind propensity score
matching is to match each participant
with an identical nonparticipant and then
measure the average difference in the
outcome variable between participants
and nonparticipants.18,23 The balancing
property test is captured by the area
of common support. It represents the
propensity scores within the range of
the lowest and highest estimated values in
the treatment group. With the propensity
scores generated, the outcomes of
interest between the treatment group
and the matched control group are then
compared to see whether the intervention
affects the outcome of interest. This
is possible by estimating the average
treatment effect on the treated (ATT)
of the programme participation, using
kernel-based matching – identified as
the most robust method. The method is
usually accompanied with bootstrapping
of standard errors. 24,25 The matching
method is meant to reduce bias by
choosing the treatment and comparison
groups on the basis of observable
characteristics.26
Table 1. Sample sizes of baseline and endline surveys
Households
Urban
Total
Rural
Treated
150
250
400
6
10
16
Control
225
375
600
9
15
24
Total
375
625
1000
15
25
40
Source: PBF-LT surveys
12
Health facilities
Rural
Urban
Total
The double difference method uses panel
data, collected from a baseline survey
before the programme was implemented
and after the programme has been
operating for some time. The DD method
can be implemented using a regression on
panel or pseudo-panel data:28
Yit = a + bTt + Ti + it + it
where T is the treatment variable, t is the
time dummy, and b is the coefficient of
the interaction of T and t. b gives the
estimate of the impact of the treatment
on the outcome Y.
The health outcomes the intervention
targets considered in the impact
modelling are: overall quality score and
its main components; human resources
availability (physicians, nurses, nurses’
aides and unqualified staff); and health
service coverage (outpatient consultation,
under-one-year-old children vaccinated
on time, unwanted pregnancy, modern
contraceptive method utilization,
institutional delivery, two or more
antenatal care visits, and pregnant women
antitetanic vaccination).
All coefficients of the model are expected
to be positive as the assumption behind
the PBF intervention is that it should
increase either the health-care quality
score, staff availability or health service
coverage.
For this study, in the case of health
facilities, panel data were used; and in the
case of households, pseudo-panel data
were used as only the same delimited
health zones were considered for the
baseline and endline surveys – but not
the same households. The DD method is
popular in non-experimental evaluations.
A basic assumption behind the simple
implementation of the DD method is
that other covariates do not change over
a few years.28,29
The DD method can be refined in a
number of ways. One way is by using
PSM with the baseline data to make sure
that the comparison group is similar to
the treatment group and then applying
double differences to the matched sample
(DD-PSM). This way, the observable
heterogeneity in the initial conditions
can be dealt with.30
Results
Figure 1. Common support derived
from double difference
The findings relate to the quality of care
at the health facility, including human
resource aspects, and curative, maternal
and children health service utilization. All
results are presented in Table 3.
Untreated: off support
Treated
Untreated: off support
Quality of care
l
0
l
l
-2
-4
l
-6
l
-8
Propensity score
Using the min-max method, the
distribution of the PSM density in the
two groups was graphed in order to
portray the common support area (see
Figure 1). As a result, the bulk of the
delimited health zones in the project area
could find a matching unit in the control
group under the matching criteria used:
catchment area population size, square of
catchment area population size, number
of qualified health personnel, square of
number of qualified health personnel and
number of qualified health personnel to
catchment area population size.
Another way to check the quality of the
matching is to test the equality of some
observables between the treated and the
control groups under common support.
Table 2 shows no significant difference
for the selected observables between the
treated and the untreated groups.30,31
Limitations of the study
Some methodological limits can be
observed in the sampling strategy used
for the data collected for this study.
Power calculations were not made
to figure out beforehand whether the
sample size was large enough to be
able to capture any impact. Only postsampling power calculations were made
with the constraint of 1 000 household
sampling size and concluded favourably.
Nevertheless, the data used still remain
potentially more robust than many studies
of the same type using routine data and
smaller sample sizes.
The three methods have very similar
differences on overall average quality
score impact (DD: 20.2/68, p<0.01;
ATT: 22.4, p<0.01; and DD-PSM:
19.2, p<0.01).
There is a positive impact score of
about 5/12 points on the institutional
quality of care (DD: 5.3, p<0.01;
ATT: 4.9, p<0.01; and DD-PSM: 5.1,
p<0.01).
The impact score on outpatient care
quality is positively significant and
close to 3/11 points (DD: 2.9, p<0.01;
ATT: 2.7, p<0.01; and DD-PSM: 2.6,
p<0.01).
The maternity quality score could
also register a significant and positive
impact score ranging from 3.6/12 to
5.3/12 points across the methods (DD:
3.6, p<0.01; ATT: 5.3, p<0.01; and
DD-PSM: 3.7, p<0.01).
On family planning quality score, a
positive and significant impact is
recorded with a magnitude of about
2.5/8 points (DD: 2.5, p<0.01; ATT:
2.6, p<0.05; and DD-PSM: 2.5,
p<0.01).
Vaccination and antennal care
quality are measured under the same
component in the quality checklist and
record a 2/7-point score impact (DD:
2.0, p<0.05; ATT: 2.0, p<0.05; and
DD-PSM: 1.9, p<0.05).
Among the three methods, laboratory
quality impact score is positive and
significant only with difference-indifference with a 1/5-point impact
difference at 0.1 margin of error (DD:
1.021, p<0.1).
On drug availability, only simple
difference method could be positive
and significant with a 3/10-point
impact difference at 0.1 margin of
error (ATT: 3.0, p<0.1).
Impact on pharmaceutical supply
availability score (1/3 point score)
is positive and significant in all three
methods with various levels of
significance (DD: 1.0, p<0.05; ATT:
1.0, p<0.1; and DD-PSM: 1.0, p<0.1).
Human resource is also a key aspect
of the quality of care at the health
facility. All three methods show a nonsignificant coefficient on physician
presence at the health centre. No
significant impact is either found on
other human resource availability:
nurses, nurses’ aides and unqualified
staff.
Health service utilization
All health service utilization indicators’
coefficients, measured by coverage
percentages, are not significant with
the exception of modern contraceptive
methods (0.085 coverage rate-difference)
for which only the kernel PSM method
yields a significant coefficient (ATT:
0.085, p<0.1).
Discussion
It is considered that PBF could impact
on the quality of health-care service
provided by contracted facilities through
a positive influence on quality of most of
the components as assessed in the study.
This may be driven by improved staff
motivation through financial bonuses
as shown by an experimental evaluation
of financial incentives on staff in the
Philippines.3 Meanwhile, laboratory and
drug availability showed mitigated levels
of impact significance. No significant
impact either was found on health
personnel availability. Moreover, all health
Table 2. Post matching mean comparison tests
Variable
Treated
Control
% bias
T
Square catchment area population size
2.1e+08
2.0e+08
2.9
0.14
p>t
0.888
Square number of qualified staff
131.34
129.81
0.2
-1.18
0.244
Population x qualified staff
1.5e+05
1.5e+05
2.2
-0.86
0.395
Catchment area population size
13318
12912
5.6
-0.01
0.989
Number of qualified staff
10.219
10.259
-0.4
-1.57
0.120
13
Table 3. Impact on quality, human resource and service utilization
DD
Diff-in-diff
DD with
kernel PSM
(DD-PSM)
Kernel PSM (ATT)
Treated
Control
Difference
Diff-in-diff
Impact on the quality of care assessed at the health facility (score)
Overall quality score (/68)
20.229***
53.440
30.950
22.490***
19.252***
Institutional quality (/12)
5.354***
8.438
3.555
4.882***
5.082***
Outpatient care (/11)
2.958***
9.938
7.221
2.716***
2.575***
Maternity (/12)
3.625***
9.688
4.374
5.314***
3.723***
Family planning (/8)
2.500***
4.375
1.759
2.616**
2.509***
Vaccination and antenatal care (/7)
1.979**
5.313
3.352
1.961**
1.914**
Laboratory (/5)
1.021*
4.688
3.769
0.921
0.688
Drug availability (/10)
1.792
8.188
5.136
3.052*
1.743
Supply availability (/3)
1.000**
2.813
1.784
1.029*
1.017*
Impact on human resources in the health facility (number of staff per facility)
Physicians
0.771
1.688
0.640
1.047
0.756
Nurses
1.896
5.063
2.105
2.957
1.926
Nurses’ aides
2.625
10.500
6.441
4.058
2.794
Unqualified staff
1.500
6.063
3.206
2.856
1.657
Impact health services utilization (coverage rates)
Outpatient consultation
-0.020
0.726
0.759
-0.033
-0.034
Under-one-year-old children vaccinated
on time
-0.036
0.803
0.833
-0.030
-0.036
Unwanted pregnancy
0.103
0.111
0.058
0.053
0.097
Modern contraceptive method
0.036
0.373
0.288
0.085*
0.036
Institutional delivery
-0.011
0.981
1.000
-0.019
-0.004
Two or more antenatal care
-0.021
0.953
0.968
-0.015
-0.011
Pregnant women antitetanic vaccination
-0.022
0.867
0.877
-0.098
-0.025
1.792
8.188
5.136
3.052*
1.743
Drug availability (/10)
Note: *P<0.1; **P<0.05; ***P<0.01
service utilization, measured by coverage
rates, was not significantly impacted by
the intervention, with the exception of
modern contraceptive methods. Actually,
it should be noted that, with the exception
of contraception, coverage at baseline of
all other health services targeted in this
study were already very high at the outset,
leaving little room for improvement.
Comparable results on service utilization
were found in the Democratic Republic
of the Congo and, to some extent, in
Rwanda.4,6
Conclusion
The pilot study indicates that the
implementation of PBF in an urban
area of Cameroon could significantly
and positively impact on key aspects
of clinical care quality without really
leveraging more utilization of health
services. These findings demonstrate that
within the framework of health PBF,
the context (urban/rural) and the list of
indicators matter as underpinning factors
of future impact. In urban settings, the
14
quality of care seems to be the most
likely area for improvement as there may
be little room to improve health service
utilization in many settings. p
Acknowledgements
We wish to acknowledge the support of the World Bank.
Meanwhile, all errors remain ours, and the opinions expressed
in this paper are ours alone and should not be attributed to
the institutions with which we are associated for this work.
We are grateful to André Arsène Bita Fouda who played a
significant role as the regional delegate for public health for
the project’s implementation. We thank Celestin Kimanuka
for coordinating the data collection process along with Simon
Mbunya. And special thanks also to Enandjoum Bwanga, the
national coordinator of the Health Sector Support Investment
Project; and to Paul Jacob Robyn, the coordinator of the
main experimental impact evaluation of the project into
the three other regions financed by the World Bank. Finally,
we gratefully acknowledge the staff and patients of the
health facilities as well as the households for the time and
information they provided.
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3
Institutions and structural
quality of care in the
Ghanaian health system
Eugenia Amporfu,i Justice Nonvignonii
Corresponding author: Eugenia Amporfu, e-mail: [email protected]
S
SUMMARY—Structural quality in the provision
of health care refers to the availability of physical
and human resources. The undersupply of such
resources in health facilities leads to understaffing,
outpatient and inpatient overcrowding and
undersupply of tools needed for the provision
of adequate health care. The provision of these
resources is very much correlated with institutional
factors, specifically governance and agent
incentives. The aim of this study is to explore the
effect of institutional factors on structural quality
in public health facilities in the Ghanaian health
system. New survey data on 62 public health
facilities across three regions in Ghana were used.
Principal component analysis was used to create
three indices for structural quality: overcrowding,
personnel and equipment. Three regressions
were run for the quality indices on institutional
factors. The results showed that regional hospitals
were the most overcrowded and had the worst
personnel shortages, but had the best performing
equipment. Internal governance was found to be
more important in reducing overcrowding than
external governance. The opposite was the case
for the equipment index. Personnel shortage
was mild in facilities with opportunities for
professional development. The study highlighted
the importance of good coordination of facility
administration with workers as well as with
government in improving quality.
tructural quality of health care
refers to the availability of the
physical and human resources
required for the provision of care. 1
Measures of structural quality include
health facilities’ physical equipment, and
measures related to staff expertise and
staff coordination and organization.1
Even though this type of quality may
not by itself ensure improved outcomes,2
it is important because it focuses on the
availability of all inputs necessary for the
provision of care, without which better
health outcomes may not exist. The
definition of structural quality used in
this study focused on the adequate supply
and functional state of resources used for
the provision of health care. Structural
quality, then, ensures access to health care,
which is necessary for the achievement of
universal health coverage.
Universal health coverage is achieved
for a given economy when all residents,
regardless of income, are able to have
access to adequate health care without
suffering financial hardship.3 One of the
important factors for achieving universal
health coverage is access to technologies
for the diagnoses and treatment of
illness. The availability of these inputs
for the provision of health care
represents structural quality. Government
intervention in the health-care market
affects structural quality. In Ghana, for
example, the government owns more
than 50% all the health facilities in the
country.4 The government is responsible
i Department of Economics, Kwame Nkrumah University of Science and Technology, Ghana
ii School of Public Health, University of Ghana
15
for the availability of all physical and
human resources in public facilities. The
structural quality of health-care provision
in the public sector is therefore subject to
public norms and institutions. This study
uses malaria outpatient data to explore the
role of institutional factors in structural
quality in Ghanaian public health facilities.
Malaria data were focused on for two
reasons. First, malaria is the most
common disease in Ghana accounting
for more than 40% of outpatient cases
and about 48% of under-five-year-olds’
hospital admissions.4 Thus, changes in
the structural quality of the treatment
of malaria are likely to affect a large
percentage of the population. Secondly,
malaria was chosen to rule out the
possible variation in structural quality as
a result of variation of diseases and hence
make comparison of quality possible
across health facilities.
Measuring structural quality
The measures of structural quality used
for this study were adequate supply of
furniture and human resources as well as
the functional state of equipment used
for treatment. These measures are closely
linked to health outcomes of treatment.
The adequacy of furniture supply was
measured by the facility’s ability to
provide enough seats for all outpatients
and beds for inpatients. Patients who do
not get seats at outpatients may have to
sit on the floor or stand and inpatients
who do not get beds may have to lie on
the floor or sit in a chair. In addition to
causing discomfort, sitting or lying on
the floor can increase the probability of
contracting germs and hence worsen a
patient’s health status. The equipment
includes tools used for diagnoses as well
as treatment of malaria. The correct
functioning of these tools is important
for proper treatment and enhanced
outcomes. The supply of doctors and
nurses is necessary to ensure access to
treatment. A well-equipped health facility
that is not staffed adequately with experts
is not capable of providing adequate care
to patients.
Institutional factors
The institutional factors relevant in
this study were mainly the model of
governance used by the government
16
for the various health facilities and the
administration of the health facilities
for the workers. Specifically, the focus
was on the extent of decentralization in
decision making at the facility level as
well as the flow of information between
the government and health facilities and
the administration of health facilities
and health workers. Teaching hospitals
in Ghana have more autonomy than
other facilities in hiring and capital
expenditure. Unlike the other types of
hospital governed by the Ghana Health
Service (GHS), teaching hospitals do not
require approval from GHS for hiring and
capital expenditure. Teaching hospitals,
then, enjoy significant decentralization.
Teaching hospitals are also referral
facilities to regional hospitals, which are
referral facilities for district hospitals,
and in turn health centres. Hospital type
then has institutional implications. In
addition, institutional factors also covered
the procurement process and incentives
for health workers. These factors were
measured through relevance and quality
of procured items, opportunities for
professional development through
further studies and learning on the job,
hiring procedure, and workers’ view of
information flow.
Method
Data
The data used for the study came from
a survey of health facilities in three of
the ten administrative regions in Ghana.
The selected regions have the three
teaching hospitals in the country. The
selected health facilities for each region
included one teaching hospital, one
regional hospital, district hospitals and
health centres. The respondents for the
survey were patients, health workers and
facility administrators. Health workers and
administrators provided information on
the institutional factors described above
but the unit of observation was patients.
Thus health workers responses were
averaged for the facilities in which they
worked. The survey, which was done in
2010, was funded by the African Economic
Research Consortium and ethically
approved by the Ghana Health Service
on clearance ID: GHS-ERC:01/1/10.
Information in the survey included
patient and health facility characteristics,
as well as institutional factors.5 The unit of
observation was patients and the sample
size, after the removal of all missing
variables, was reduced from 2 852 to 2 451
patients. There was no information on the
patient population serviced by the selected
facilities and so convenience sampling
was used.
Empirical specification
The regression equation used for the
study is:
Yi =  + aCi + Hi + Si + i
Where yi is the dependent variable(s),
C i is a vector of variables on the
patients’ characteristics, Hi represents
a vector of characteristics of the health
facility in which the patient received
care, and Si is a vector of variables on
institutional factors as described above.
The patient characteristics included age,
gender, education and employment.
Facility characteristics focused on
facility type and the region in which
it was located. The facility types were:
teaching hospital, regional hospital,
district hospital and health centre; and
the regions: Ashanti, Greater Accra and
Northern. Both the facility types and
regions were coded as dummy variables
with health centre and Northern region
as the control variables.
There were five indicators for structural
quality: outpatient overcrowding,
inpatient overcrowding, functional state
of equipment, doctor shortage and nurse
shortage. Facilities without inpatients
were coded as having no inpatient
overcrowding. All indicators were dummy
variables and were coded as one if the
problem (e.g. nurse shortage) existed and
zero otherwise. The coding for personnel
shortage was first in the form of dummy
variables and second as a ratio of available
personnel in a facility to the required
number of personnel.
Principal component analysis, explained
below, was used to create quality indices
from the five indicators. The indices
were used as dependent variables for the
regressions. The independent variables
for the regressions differed only by
the institutional factors as different
institutional factors were relevant for
different indices.
Principal component analysis was used
to reduce the number of regressions for
structural quality, and to create quality
indices. Generally, principal component
analysis is used to reduce a large number
of apparent independent variables to a
smaller number of uncorrelated variables
referred to as principal components. The
indicators of structural quality again
were doctor shortage, nurse shortage,
the functional state of equipment,
outpatient overcrowding and inpatient
overcrowding. In general, doctors are
scarcer than nurses and so facilities with
nurse shortages are also likely to have a
shortage of doctors. Poorly functioning
equipment/instrument can delay service
and hence worsen any existing personnel
shortage. Overcrowding (outpatient
and/or inpatient) leads to overuse of
equipment and hence weakens their
functional state. Thus all indicators could
be correlated. The principal component
analysis involves the computation of
independent composite variables called
principal components. 6 A principal
component is the sum of the product of
each indicator with its weight:
Where a represents the weight placed
on each indicator and I represents an
indicator. Since there are five indicators
in this study k equals five. The principal
components that were created from the
five indicators were used in this study as
structural quality indices.
PCi = a1 + I1 + a2 I2 + ... + ak Ik
The literature typically reports only the
principal components with eigenvalues
Results
Principal component analysis
results
The results of the principal component
analysis that used the ratios for personnel
shortage had very large positive weights
and hence created large and positive
personnel indices. However, a dependent
variable with only positive values is likely
to cause biased estimation as some of the
predicted values of the estimation can be
negative. A typical solution in such a case
is to transform the variable into natural
logs. However, such a transformation in
the current study could create difficulty
with the interpretation of the results. The
analysis then used dummy variables for all
quality indicators.
greater than one which in this case applies
to the first two principal components only
(1.484 and 1.385) but these explained only
57.4% of the variation in the current
data and so the third component, with
an eigenvalue of 0.972, which is close
to 1 was also reported to increase
the variance. The first three principal
components together explained 76.817%
of the variation in the five indicators. The
results are reported in Table 1.
Table 1. Component matrix
Component
1
2
3
.830
.185
.064
Functional state of
equipment
-.336
.086
.928
Nurse shortage
-.107
.814
-.124
.809
.080
.301
-.124
.821
-.018
Inpatient overcrowding
Outpatient overcrowding
Doctor shortage
The first principal component had
large positive weight for inpatient and
outpatient overcrowding and small (in
absolute value) negative weight for
functional state of equipment. Facilities
that got high positive scores for this index
thus had a serious space and bed shortage
problem and those with large negative
(in absolute value) scores had poorly
functioning equipment. Thus scores
which are close to zero represented good
functional state of equipment and no or
low doctor and nurse shortages. The first
principal component then was referred to
in the study as the overcrowding index.
The second principal component had
only positive weights with the largest
for doctor and nurse shortages and the
lowest for functional state of equipment
and outpatient overcrowding. Thus, a
high score for this index represents a
high shortage of personnel, hence called
the personnel index. The third principal
component had a large positive weight for
functional state of equipment and negative
for personnel shortage. The facilities
with poor functional state of equipment
then would score high in this principal
component. The principal component was
therefore called the equipment index. The
three components were used as structural
quality indices for the regression.
For each observation, the dependent
variable equalled the quality index of the
facility in which service was provided for
17
Table 2. Results on structural quality indices
Dependent variables
Overcrowding index
Independent variables
Constant
Personnel index
Coefficient
P-value
Coefficient
P-value
-16.060
0.005
0.923
0.000
Equipment index
Coefficient
.698
P-value
0.000
Ci – Patient characteristics
Age
-0.01
0.853
0.000
0.587
0.000
0.615
Gender (Female=1)
2.401
0.108
0.033
0.061
0.008
0.253
6.071
0.045
-0.036
0.313
-.063
0.000
Junior secondary school
Primary education
-1.298
0.502
0.096
0.000
0.002
0.859
Senior secondary school
-0.283
0.909
0.074
0.013
-0.039
0.001
Tertiary education
4.098
0.209
-0.004
0.907
-0.036
0.023
Employed in formal sector
7.520
0.008
0.245
0.000
-0.016
0.229
Informal sector employed
Farmer
2.661
0.217
0.099
0.000
-0.059
0.000
-3.883
0.159
0.181
0.000
-0.035
0.007
Hi – Health facilities
5.182
0.069
-0.508
0.000
0.068
0.000
Ashanti region
Greater Accra region
-10.975
0.000
-0.259
0.000
-0.002
0.886
Teaching hospital
-15.948
0.006
-0.295
0.000
0.257
0.000
Regional hospital
22.683
0.000
0.015
0.770
-0.264
0.000
0.185
0.000
0.074
0.000
0.129
0.000
-13.994
0.000
Number of nurses
District hospital
-0.076
0.041
Number of doctors
0.252
0.000
-32.986
0.000
Si – Institutional factors
Workers’ view of information
flow
Learning on the job
Professional development
0.977
0.002
Quality of items procured
18.771
0.000
-.085
0.000
Relevance of procurement
12.265
0.000
-.175
0.000
-0.053
0.000
0.119
0.000
Hiring procedure
Job satisfaction
Information between
government and health facility
-0.099
0.968
Information between facility
administration and workers
-9.035
0.005
the patient. To ensure the results were
unbiased and precise, specification tests
(RESET) as well as the White’s general
heteroskedasticity tests were run and the
results showed no specification problem.
The ordinary least squares estimation
method was used for the estimation of
the structural quality regressions.
Regression results
With the exception of the formal
sector and primary education, patient
characteristics did not affect the
overcrowding index. The results show
that patients with primary education
and/or working in the formal sector
are likely to receive care in overcrowded
facilities. While there was no statistically
significant difference in overcrowding
between the Greater Accra region
and the Northern region (the control
variable), the Ashanti region was the
least overcrowded. Regional hospitals
18
0.000
-0.125
0.386
0.000
-0.174
0.000
0.141
0.000
were highly overcrowded (coefficient:
22.683) relative to health centres, while
teaching and district hospitals were less
overcrowded than the health centres.
The institutional factors were all
significant with the exception of
the flow of information between
government and facilities. The flow of
information between health workers and
administration reduced overcrowding.
Improvement in quality and relevance
of procurement increased overcrowding.
The patient characteristics that affect
the personnel index were, occupation of
patients, level of secondary education. All
were positively correlated with the index.
A t-test for the equality of the coefficients
of the Greater Accra and Ashanti regions
showed that Greater Accra has the least
personnel shortage problem followed by
the Ashanti region and hence personnel
shortage is most serious in the Northern
region. The coefficient of teaching
hospitals was negative implying that
personnel shortage was more serious in
health centres than teaching hospitals.
While there was no statistically significant
difference between health centres and
regional hospitals, district hospitals were
more likely to have personnel shortages
than health centres.
The institutional factors showed that
facilities with good information flow
between administration and health-care
workers were likely to have personnel
shortage problems. As expected,
personnel shortage was higher in facilities
in which understaffing was likely to
result from hiring procedures. However,
facilities that provide opportunities for
personnel development, and/or those
in which health workers have high job
satisfaction were associated with low
personnel shortages.
The results on the equipment index show
that age, gender, secondary education
levels and employment in the formal sector
have no correlation with the equipment
index. The higher education and other
employment coefficients were all negative
and significant implying that patients with
higher education and are employed are
likely to receive care in facilities with good
equipment. The facility characteristics
coefficients show no significant difference
between the functional state of equipment
in the Ashanti and Northern regions but
a significantly poorer functional state of
equipment in the Greater Accra region
relative to those in the Northern region.
The equipment of teaching and district
hospitals was found to be in a poorer
functioning state while that of the
regional hospitals was better than that of
health centres.
The results on institutional factors show
that after controlling for quality and
relevance of procurement, facilities with a
good flow of information were associated
with equipment in a poor functional state.
The functional state of equipment in
facilities that are favoured by government
policies was also good.
Discussion
The results on overcrowding across
regions imply that the problem of
overcrowding is less severe in the
Ashanti region than other regions, and
in teaching and district hospitals than
regional hospitals. These are interesting
results because the Ashanti region
is the most populous region with the
largest number of people per health
facility.7 The Ashanti region then, in
spite of its large population, was better
able to accommodate its patients, both
at outpatient and inpatient levels, than
the other regions. Teaching and district
hospitals may have large number of
patients regardless of the region in
which they were located. The results here
imply that these hospital types had more
furniture to accommodate patients than
health centres which might have smaller
numbers of patients.
The results on institutional factors also
imply that any government policy that
could favour facilities did not have any
significant impact on the problem of
overcrowding. Results on the other
institutional factors show that good
coordination between health workers and
the administration reduced overcrowding
in the facilities, implying that the solution
to overcrowding could be better solved
internally than at the government level.
The positive relationship between the
overcrowding index and the quality and
relevance of procurement could be that
facilities that were able to procure quality
items were able to attract more patients
and hence become overcrowded.
Relating the result on district hospitals
to the overcrowding index implies that
even though personnel shortage was a
problem at the district hospital level,
district hospitals had enough furniture
to accommodate patients to reduce
overcrowding.
The reason for the negative effect of
information flow on personnel shortage
could be that good flow of information
improves performance, all things being
equal, and this could increase the number
of patients and hence lead to a shortage
of personnel. Such a result is important
because personnel development enhances
workers’ productivity and hence improves
job satisfaction. The implication is that
when job satisfaction increases, workers
are able to increase efforts such that any
problem caused by personnel shortage is
mitigated.
In the case of the equipment index, good
information flow could motivate workers
to put in extra effort in performance which
might lead to overuse of equipment.
Also, the results imply that involving
health-care workers in the procurement
procedure may not necessarily imply good
functional state of equipment but it is
the relevance and quality of the product
as well as the skill of the workers and
the involvement of the government that
ensure good functioning equipment.
Teaching hospitals performed well in
all three indices while regional hospitals
performed poorly in all three. Since the
teaching hospital variable also represents
decentralization, the result could mean
that decentralization is quality improving
for large referral health facilities.
Limitations of the study
The use of convenience sampling could
have the disadvantage of making the data
less representative of the population.
To minimize such an effect, the number
of patients interviewed for the larger
facilities was always greater than for
the smaller facilities. Another limitation
is that the data lacked information on
patient income, which is likely to affect
their choice of health facility and hence
the corresponding quality index.
Conclusion
The study has shown that institutional
factors relating to governance play
a very important role in affecting the
availability of physical and personnel
inputs needed for the provision of
health care. Specifically, decentralization
and good coordination between facility
administrator and health workers
are very important factors affecting
structural quality. The study recommends
decentralization of regional health
facilities and improvement of information
f low and coordination between
administrators and health workers. p
Acknowledgement
The authors would like to acknowledge the financial
contribution of the African Economic Research Consortium for
the collection of data.
References
1. Birkmeyer JD, Dimick JB, Birkmeyer NJO. Measuring the
quality of surgical care: Structure, process, or outcomes?
J Am Coll Surg 2004; 198(4):626–632.
2. Peabody JW, Nordyke RJ, Tozija F, Luck J, Muñoz JA,
Sunderland A, Desalvo K, Ponce N, McCulloch C. Quality
of care and its impact on population health: A crosssectional study from Macedonia. Soc Sci & Med 2006;
62(9):2216–24.
3. World Health Organization. What is Universal Health
Coverage? Available: http://www.who.int/features/qa/
universal_health_coverage/en/ [accessed 9 June 2015].
4. Ghana Ministry of Health. Health sector facts and figures.
Ghana Ministry of Health 2012. Available: www.mohghana.org [accessed 10 July 2015].
5. Amporfu E, Nonvignon J, Ampadu S. Effect of institutional
factors on the quality of care in the Ghanaian health
sector. J Afr Dec 2013; 15(1).
6. Kennedy P. A Guide to Econometrics (5th edition).
Massachusetts: MIT Press 1998.
7. Ghanadistricts.com. Ashanti region, population
characteristics. Available: http://www.ghanadistricts.
com/region/?r=2&sa=12 [accessed 9 June 2015].
19
4
Solidarity in communitybased health insurance
in Senegal: Rhetoric or
reality?
Philipa Mladovsky,i Pascal Ndiayeii
Corresponding author: Philipa Mladovsky, e-mail: [email protected]
C
SUMMARY—Continued low rates of enrolment
in community-based health insurance (CBHI)
suggest that in many countries strategies proposed
for scaling up have not been well-designed or
successfully implemented. One reason may be
a lack of systematic incorporation of social and
political context into CBHI policy. In this study,
solidarity in CBHI is analysed from a sociological
perspective in order to answer the following
research questions: What are local definitions and
perceptions of solidarity in CBHI? To what extent
are these borne out in practice? Three case studies
of Senegalese CBHI schemes using specific criteria
were studied. Transcripts of interviews with 64
CBHI stakeholders were analysed using inductive
coding. A conceptual framework of four dimensions
of solidarity (health risk, vertical equity, scale and
source) was developed to interpret the results.
The results suggest that the concept of solidarity
in CBHI is complex. Each dimension and source of
solidarity was either not borne out in practice or
highly contested, with views diverging between
stakeholders and the target population. This
suggests that policy-makers need to engage in
a more rigorous public discussion of solidarity
as regards CBHI and universal health coverage
policy more widely, in order to move towards
policies which both resonate with and meet the
expectations of the people they aim to serve.
ommunity-based health insurance
aims to provide financial
protection from the cost of
seeking health care through prepayment
of premiums by community members.
It is typically not-for-profit and aims to
be community owned and controlled.1 In
most low- and middle-income countries
(LMIC), population coverage of CBHI
remains low.2 Health systems literature2–4
proposes the following strategies to
improve coverage: public funding
to subsidize premiums for the poor;
promoting increased revenue collection
from the “healthy and wealthy” so as
to enhance cross-subsidization and risk
pooling; improved CBHI management;
and improved purchasing to enhance
quality of care. Yet continued low rates of
CBHI enrolment suggest these strategies
have not been successful. Mladovsky and
Mossialos5 have argued that an underlying
reason for poor CBHI policy design
and implementation may be a lack of
systematic incorporation of social and
political contexts into analysis. This echoes
a wider call for the greater incorporation
of social science perspectives into health
policy and systems research.6
In this study two of the main strategies
for expanding CBHI coverage (public
funding to subsidize premiums for the
poor; and increased revenue collection
from the “healthy and wealthy” to
enhance cross-subsidization and risk
pooling) are analysed from a sociological
perspective. Specifically, the following
research questions are addressed: What
are local definitions and perceptions of
solidarity in CBHI? To what extent are
these borne out in practice?
20
i LSE Health, London School of Economics and Political Science, London, United Kingdom
ii Institute of Tropical Medicine, Antwerp, Belgium
The study focuses on Senegal. Senegal’s
health system operates according to cost
recovery through user charges. Private
expenditure on health as a percentage of
total health expenditure is 41.7%; 78.5%
of that is spent directly out-of-pocket.7
Since 1997, successive governments have
viewed CBHI as a key mechanism for
achieving universal coverage.8,9 Senegal
has witnessed a rapid increase in the
number of CBHI schemes (mutuelles de
santé), increasing from 19 to 130 between
1997 and 2006.4 However, coverage in
Senegal remains 4% of the population
at most.2 A policy of exemptions from
user charges is also in place,10 but these
initiatives have experienced difficulties
with implementation and have hardly
been evaluated.2
Methods
A multiple case study design was used.
Three Senegalese regions (out of 10)
were selected for inclusion in the study:
Thiès, Diourbel and Dakar. This ensured
the inclusion of a range of geographic
contexts in the study. The three regions
had a relatively high number of CBHI
schemes (Table 1), meaning the study
focused on settings where CBHI was at a
relatively advanced stage and a diverse set
of stakeholders had had the opportunity
to develop.
In each of the three regions, one case
study (CBHI scheme) was selected.
Local documentation and knowledge of
local experts were used to identify the
three cases according to a set of key
criteria (Box 1). Only schemes which
had achieved a basic measure of success
(above average enrolment and duration)
were included. This ensured that schemes
were not experiencing fundamental and
irreversible supply-side failures. Another
objective was to select schemes with high
drop-out. The rationale was to focus on
contexts where there was potentially the
most to gain from a policy intervention.
Drop-out from CBHI is not only a
major obstacle to increasing population
coverage in Senegal but also elsewhere in
sub-Saharan Africa.11 Soppante, Ndondol
and Wer Ak Werle (WAW) were the three
schemes selected (Table 2).
Table 1. Number of CBHI schemes in
Senegal by region
Region
CBHI schemes in 2003
Dakar
44
Thiès
39
Kaolack
11
Diourbel
10
St Louis
9
Louga
8
Ziguinchor
8
Tambacounda
5
Fatick
4
Kolda
Senegal total
Sixty-four interviews were conducted
(Table 3). The fieldwork and analysis
were done in French. Quotations were
translated into English for the purpose
of this paper.
The interviews were part of a broader
study which investigated the relationship
between social capital and CBHI coverage
and included a household survey, semistructured interviews and focus groups
with members and non-members of the
CBHI schemes. The results of the rest
of the study are published elsewhere.13–15
1
139
Source: Ministère de la Santé, 2004
Note: Figures include complementary voluntary private health
insurance companies and CBHI schemes
Fieldwork was conducted from March to
August 2009. Stakeholders were identified
using purposive snowball sampling.12
Stakeholders were defined as individuals
who affected or could affect the CBHI
scheme. Sample size was determined by
the data obtained and data collection
continued until saturation. The interviews
were conducted primarily by the authors
and were of a focused, open-ended type.
Each interview lasted one hour on average.
The topic guide focused on the following
themes: personal professional history,
knowledge of the scheme, relationship
with the scheme, participation in the
scheme, perceptions of the scheme and
other stakeholders and relevance of the
scheme to local health sector priorities.
All interviews were recorded and
transcribed using verbatim transcription.
Inductive coding 16 was performed in
Nvivo.8 Segments of interview text were
coded by one author. As new codes
emerged all transcripts that had been
previously coded were read again and
the new code added where appropriate.
During the coding process, periodic
meetings were held between the authors
to review codes. Towards the end of the
process, no new codes were added, at
which point it was concluded that all major
themes had been identified. Stakeholder
validation was performed by presenting
preliminary results to approximately
50 national and local Senegalese CBHI
stakeholders in Dakar in 2011. Ethical
approval for the research was obtained
from the Senegalese Ministry of Health.
BOX 1
Case study selection criteria
CBHI schemes, which varied according to the following contextual characteristics, were selected:
• Geographic zone;
• The type of economic sector of the target population.
Further selection focused on the level of development of CBHI schemes. Only CBHI schemes which met the
following core criteria were considered for selection in the study:
• The CBHI schemes had enrolled a greater than average number of households (the average number of
households enrolled in a CBHI scheme was 329 (Hygea, 2004) (this affected population coverage). In Senegal,
enrolment in CBHI is typically on a household basis. A representative of the household enrols in the CBHI
scheme and purchases a membership card on which a certain number (typically up to 12) other household
members may be registered. The premium is then paid monthly.
• The schemes had a relatively high proportion of members who had ceased paying the monthly premium and
whose insurance policy had therefore expired (the national average rate was 47% in 2004 (Hygea, 2004) (this
also affected population coverage).
• The CBHI schemes were currently operational and had been established for a minimum of eight years.
• Variation in the tier of the health system contracted by the scheme (this affected the scope of coverage, i.e.
the benefit package).
Ref: Hygea, 2004. Equité et mutualité au Sénégal (Equity and mutuality in Senegal). IDRC/CRDI, Université de Montréal
and Hygea, Dakar.
21
Table 2. Characteristics of the selected cases
Scheme characteristics
Context
Name of CBHI scheme
Number of
households ever
enrolled
Number of
households
currently enrolled
(and proportion of
members whose
policy had expired)
Year scheme
started
Tier of services
contracted by the
scheme
Region
Geographic zone
Characteristics
of the population
targeted by the
scheme
Soppante
986
197 (80%)
1997
Health post
Hospital
Thiès
Mostly rural
Formal and
informal sectors
Ndondol
464
135 (71%)
2001
Health post
Health hut
Maternal and child
health centre
Diourbel
Rural
Informal
agricultural sector
Wer Ak Werle (WAW)
678
278 (59%)
2000
Health post
Health centre
Pharmacy
Dakar
Urban
Predominantly
informal sector,
female petty
traders
Table 3. Stakeholders interviewed
Number of individuals interviewed
Type of stakeholder
Soppante
Ndondol
WAW
Health service providers
8
4
3
Staff of the CBHI scheme
4
6
4
Local leaders (religious, traditional, political, associations,
local NGOS)
3
10
8
Donors, international organizations
Total
Results
A total of 88 codes were identified in
the coding analysis. The codes pertaining
to solidarity were selected for further
analysis in this paper. Results pertaining to
related codes, such as trust, voluntarism
and altruism are not discussed here
(see 14 for a more extensive analysis).
The interviewee identifiers indicate which
scheme and stakeholder the quotation
derives from (S = Soppante, N =
Ndondol, W = Wer Ak Werle (WAW)).
Most stakeholders in all three cases viewed
the cross-subsidization of resources
from healthy to sick people to be not
only a form of risk pooling but also an
expression of solidarity (Box 2, S3). Several
stakeholders said the solidarity inherent
in CBHI contributed to fighting poverty
and promoting community development.
Many stakeholders viewed CBHI to be
part of a wider local community social
structure of associations which promoted
solidarity (Box 2, N4).
Each scheme sought to draw on different
sources of solidarity. Soppante was
founded by individuals who had previously
been leaders of a local Catholic CBHI
22
5
4
5
20
24
20
scheme. The church mandated that only
Catholics were eligible for membership
of the Catholic scheme. The founders
of Soppante objected to the churchbased model of CBHI on the grounds
that it prevented scaling up solidarity
between different religious groups. They
therefore left the Catholic scheme in
order to create Soppante, which was open
to all residents of a large geographic zone
(Box 2, S19). Meanwhile, stakeholders in
WAW had sought to mobilize existing
solidarity structures by integrating the
scheme into a women’s microfinance and
income generation association (Box 2,
W12). The scheme had enrolled a large
number of women from this association
and the collection of premiums from
the women had been decentralized to
groups known as groupement mutualiste de
santé (GMS). In the GMS groups, field
staff collected premiums from women
they regularly worked and socialized
with. Stakeholders said that the existing
solidarity among the women encouraged
them to enrol and remain enrolled in
CBHI. The GMS served as an interface
between the members and the central
management of the CBHI. However,
a perceived disadvantage of the GMS
system was that it excluded people who
were not in GMS groups from the scheme
(Box 2, W8b). In fact, men and women
who were not in GMS groups were
eligible to enrol in WAW but they had to
pay premiums directly to the scheme staff
rather than through the GMS system.
Finally, in contrast, in the third case
study (Ndondol), there was no particular
strategy for mobilizing solidarity in the
target community. All people residing in
the district of Ndondol were eligible for
enrolment in the scheme.
A lack of solidarity at the individual level
was viewed by some stakeholders as the
main reason for households dropping out
of or failing to enrol in CBHI (Box 2,
W8a). The alternative explanation that
poverty was the main reason for dropout and lack of enrolment, frequently
put forward by households in the target
population, was rejected by several
stakeholders. These stakeholders argued
that the CBHI premium was affordable
and noted that poverty did not prevent
the majority of the population from
participating in various regular social
events and local associations which had
far higher fees than CBHI (Box 2, W7).
However, other stakeholders pointed
out that CBHI schemes were different
to other community associations. They
argued that CBHI lacked solidarity, due to
the fact that members were only eligible
for benefits if they paid the premium; in
contrast, in other types of community
associations, people could benefit even
if they had not paid membership fees, as
the association would contribute on their
behalf using collective funds (Box 2, S10).
Most CBHI stakeholders, however, did
concede some very poor households
BOX 2
Selected stakeholder quotations on solidarity in CBHI
S19
N4
Solidarity is ... rooted in our customs
... There are our women who have
their groups; we have our dahiras
(Muslim associations). Now we need to
interest people in this other form of
solidarity, CBHI. (Provider of technical
assistance to CBHI schemes)
S3
You see, it is a symbol of solidarity.
Even if you don’t receive health
services in exchange for your
money, somebody else does and
that’s a huge gesture. That’s CBHI.
(Local field staff member)
W7
W8a
Some people don’t have much
solidarity and so they say to
themselves, “I’m not going to fall
ill so why should I continue paying
the premium? I am just paying for
other people” (Local community
association leader)
W8
The church CBHI schemes were quite
restrictive; they were reserved for
Catholics … which excludes a large
part of the population. This principle is
contrary to the philosophy CBHI. It is in
this context that Soppante was born.
(Provider of technical assistance to
CBHI schemes)
Some tell me (their lack of enrolment)
is because of the (financial) crisis
... I don’t follow this, because they
often contribute CFA 1 000 per week
for events, ceremonies and other
things in the neighbourhood so why
not CFA 1 000 per month (for the CBHI
premium)? (CBHI scheme leader)
Political parties, the largest in the
country, have … done nothing
tangible; people who should
embody certain values, do not ...
(Local youth leader)
W12
W8b
CBHI ... must be there
for everyone and
not everybody is in
a women’s group ...
(Local community
association leader)
We experimented with several approaches. We
moved from an individual prepayment system, to
family enrolment in CBHI and over the last four
years this has evolved into CBHI based on (women’s)
groups ... When you adopt a family model, without
realizing it you are breaking solidarity mechanisms
at the community level. (Provider of technical
assistance to CBHI schemes)
S10
Some CBHI members quit
the scheme because they …
had not paid their premium
… Note that in dahiras
there is solidarity between
members. If a member is
faced with a lack of revenue,
we take a certain amount
out of the central fund to
help them. In contrast,
in CBHI, when you need
treatment, you can only
benefit if you present your
membership book (Local
community association
leader)
Note: The CFA (Central and Western African Franc) has a fixed exchange rate to the euro: CFA 100 = €0.152449 (€1 = CFA 655.957). Equité et mutualité au Sénégal (Equity and mutuality in
Senegal). IDRC/CRDI, Université de Montréal and Hygea, Dakar.
were unable to afford the premium,
acknowledging that this situation
undermined solidarity. This led some
stakeholders to argue that CBHI schemes
needed premium subsidies from local
government. In all three cases, the
CBHI scheme leaders had lobbied local
government for subsidies but had not
been successful at the time of fieldwork.
Different stakeholders had different
explanations for this. A local government
official claimed it was because there were
insufficient funds. However, several (nongovernmental) stakeholders believed the
reason was rather the lack of political
capital to be gained from supporting
CBHI. There was also a belief among
some stakeholders that politicians did
not uphold the values which they saw
CBHI to embody, including solidarity
(Box 2, W8).
Discussion
The following discussion uses sociological
theory to analyse the stakeholders’
discourse on the role of solidarity in
CBHI. Furthermore, quantitative data
from the same field site published
elsewhere 13,15 are contrasted with
stakeholders’ perceptions of solidarity.
It is argued that incoherence on the issue
of solidarity was an important source
of the underlying weakness of CBHI
and prevented the development of clear
strategies to increase population coverage.
Overall, the results reveal that in general,
most stakeholders in the three case
studies viewed CBHI to be a solidarity
mechanism. The idea that solidarity
increases population coverage ostensibly
echoes the ethos of solidarity that is
deeply rooted in social health insurance
in western Europe 17 and its 19thcentury antecedent, mutual aid societies,
on which the model of CBHI in West
Africa is based.18 Indeed, international
development agencies as well as Catholic
missionaries were crucial to the transfer
of the European model to CBHI in
Senegal (and elsewhere) and it is likely
that the Senegalese discourse around
solidarity in CBHI partly has its roots in
this process. The Senegalese discourse
on solidarity in CBHI also appears to
reflect the current broader international
policy focus on strengthening solidarity in
African health financing systems through
social health protection.19
Yet quantitative data from the study13,15
suggest that scheme members did not
view CBHI as a solidarity mechanism,
23
as less than half of all current and exmembers of all three schemes stated
they believe “solidarity” is an advantage
of the scheme (there are no significant
differences between current and exmembers in terms of holding this view).
The divergence in opinion may indicate
a lack of understanding among the
target population of the redistributive
principles of CBHI. It may also indicate
that stakeholders understand solidarity
differently to the target population,
as there may have been a variety of
interpretations of “solidarity” at play
in the Senegalese case studies. In order
to understand these issues better, we
developed a conceptual framework
consisting of four dimensions of
solidarity in CBHI that emerged from
the study: health risk, vertical equity, scale
and source.
Health risk
The first dimension constitutes
Senegalese stakeholders’ focus on crosssubsidization of the sick by the healthy.
They believed that this solidarity should
be an important motivating factor for
people to enrol in CBHI. This “health
risk” dimension presents solidarity as a
potential mechanism for overcoming a
classic market failure in private health
insurance, adverse selection (where
high-risk sick individuals are more likely
to buy health insurance than low-risk
healthy individuals). Quantitative studies
of CBHI in sub-Saharan Africa confirm
that adverse selection is an issue in some
contexts,20,21 although not in others.22,23
The results of this study reveal that
several stakeholders expressed concern
that “health risk” solidarity was weak
in the target population, observing that
CBHI members often gave not falling sick
as a reason for dropping out of CBHI.
In practice, stakeholders’ fears seem to
have been well-founded: current member
households were twice as likely to have
had an illness, accident or injury, and
nearly twice as likely to have a disability,
than ex-member households. 13 This
undermines the idea that CBHI drew
on high levels of solidarity in terms of
the cross-subsidization of the sick by
the healthy.
24
Vertical equity
The second dimension of solidarity
identified in the results of this study is the
cross-subsidization from wealthy to poor;
this is termed “vertical equity” in the
health economics literature.24 In practice,
vertical equity is likely to overlap with
the “health risk” dimension of solidarity
(because poor health is associated with
poverty) but in the interviews, people
clearly distinguished between these
two dimensions of solidarity. Vertical
equity is achieved in some social health
insurance and mutualities in Europe
where contributions are progressive (the
proportion of income paid increases
as income increases). In contrast, flat
rate premiums in CBHI meant that the
very design of CBHI was regressive.
This is typical of CBHI more widely.3
The regressivity of CBHI made it more
likely for wealthier households to enrol in
CBHI compared with poorer households
(because wealthier households paid a
relatively smaller premium than poorer
households, in terms of payment as a
percentage of total household wealth,
income or expenditure), both in the
present study 15 and more widely in
Senegal and elsewhere.25
A policy of progressive CBHI premiums
was not an explicit objective of the
stakeholders. However, the stakeholders
who sought government subsidies to
cover the premiums of the poor did
implicitly support the notion of vertical
equity. Current CBHI members also
seemed to support this dimension of
solidarity: they reported having more
solidarity than ex-members in relation
to their views on whether the scheme
should cover poorer households, being
more likely to agree that members of
the scheme should sponsor families who
are very poor; members should support
families who are very poor by increasing
the amount of their contribution; and
families who are very poor should be
members of the scheme without paying.13
It is important to note that studies from
other sub-Saharan African countries
have found that while progressive health
financing has widespread support, large
segments of the population (particularly
the relatively wealthy) are not in favour
of this principle, 26,27 suggesting that
this dimension of solidarity in CBHI
may be difficult to achieve in practice in
these contexts. Furthermore, crucially,
as in many other LMIC, the difficulty
of identifying poor households due to
inadequate targeting mechanisms and the
large size of the informal sector is likely
to pose a further challenge to achieving
vertical equity through progressive
premiums or subsidies.3
Another issue is whether establishing
progressive premiums payment and/
or government subsidies for CBHI
would be cost-effective; a study from
Cambodia and the Lao People’s
Democratic Republic suggests not, since
it found that the same level of access
for the poor could have been achieved
with a lower subsidy if the subsidy was
used as a direct reimbursement of user
charges to the provider rather than
through the CBHI scheme.28 Taking a
political perspective, however, the efforts
of CBHI leaders to gain demand-side
subsidies may have had the advantage
of mobilizing users’ participation and
possibly empowerment.29
Scale
The third dimension of solidarity is the
scale of risk pools. By design, CBHI
promoted cross-subsidies within small
groups. However, stakeholders in Senegal,
echoing the international literature, 30
recognized that small risk pools are
unappealing from the perspective of
solidarity as larger and more diversified
risk pools allow more effective crosssubsidization of risk. This limited “scale”
dimension undermined the ability of
CBHI to promote solidarity. This is
discussed further below.
Source
The fourth dimension relates to the
source of solidarity. The sociologist
Durkheim31 proposed that while kinship
networks are the most fundamental and
universal solidarity mechanism, solidarity
changes as a society becomes more
complex. In traditional societies, solidarity
is based mainly on shared identity, social
sanctions and authority of the collective
and is typically organized around kinship
affiliations (this is termed “mechanical
solidarity” by Durkheim). In larger
more complex industrialized societies,
solidarity is instead based on integration
of specialized economic and political
organizations and emphasizes equality
among individuals, social interdependence
and modern legal structures such as
civil, commercial law (termed “organic
solidarity” by Durkheim). Since CBHI
extends cross-subsidization beyond
kinship ties, it should be interpreted as
a mechanism for promoting “organic
solidarity”. Supporting this idea is the
fact that CBHI has emerged in the
context of a general increase in numbers
of community associations in Senegal,32
a trend which is arguably indicative
of the social transition described by
Durkheim. Indeed, the results of studies
of poor urban populations in Senegal
find that high levels of social and
cultural heterogeneity caused by large
flows of rural to urban migration have
resulted in a plethora of associations
emerging to replace traditional social
safety nets. 33 These include rotating
credit associations (ROSCAs) 34 and
dahiras (groups which form part of the
Muslim brotherhoods) which primarily
have a spiritual purpose but also bring
many economic and political advantages
to their members.35,33 The quantitative
results of this study suggest that the more
individuals experienced and presumably
benefited from this type of modern
associational “organic” solidarity, the
more they were willing and able to invest
further in similar solidarity structures,
as members of CBHI were statistically
significantly more likely to be enrolled
in another community association than
non-members, controlling for wealth and
other socioeconomic variables.15
More recent sociological literature can be
used to further distinguish between four
different sources of organic solidarity:
cultural similarity, concrete social
networks, functional integration (i.e.
interdependence based on flows of goods
or services), and mutual engagement in
the public sphere.36 Most stakeholders
advocated CBHI risk pooling based
on cultural similarity or concrete social
networks (e.g. schemes for Catholic
parishioners or networks of women, as
in the case of WAW), since, as discussed,
this type of solidarity was already
flourishing in Senegal. These stakeholders
hoped that by merging with other
community associations, CBHI would
tap into existing, popular, essential forms
of solidarity. This argument is founded
on the commonly held idea that cultural
similarity and concrete social networks
“trump” other sources of solidarity.36
However, a counter argument was raised
by other stakeholders and community
members that providing health insurance
through community associations
promoted too narrow a form of
solidarity and excluded people who did
not already belong to any community
groups. As such, the idea that CBHI
promotes or constitutes solidarity was
again problematized. The alternative
approach would be an increased focus on
functional integration. This could include
promoting social health insurance in the
formal sector and national professional
associations in the informal sector at the
national level, with alternative financing
arrangements for those who belong to
neither group. This could be enhanced by
mutual engagement in the public sphere,
for example by launching national public
campaigns promoting risk pooling and
cross-subsidization. This would be similar
to the approach taken in Ghana where
CBHI was replaced with a national health
insurance scheme (NHIS) with premium
subsidies for certain vulnerable groups.
In sum, the concept of solidarity in CBHI
was complex, with stakeholders’ discourse
incorporating four dimensions and four
sources of solidarity. Each dimension and
source of solidarity was either viewed as
desirable but not borne out in practice,
or highly contested with views diverging
between stakeholders and the target
population. Furthermore, although the
research used an open-ended interview
technique and an inductive approach
to coding the interview transcripts, it
is possible that other dimensions of
solidarity were at play that were not
captured by the interviews. Future
research would benefit from considering
ethnography in order to allow a more
25
comprehensive understanding of
solidarity in CBHI. Implications of the
study for CBHI policy and for universal
health coverage more widely are discussed
in the next section.
Conclusions
In all three schemes there were serious
contradictions and inconsistencies within
stakeholders’ discourse about solidarity;
and between stakeholders’ discourse about
solidarity on one hand and the target
population’s views and behaviours as
regards solidarity on the other. In practice,
the four dimensions of solidarity (health
risk, vertical equity, scale and source) were
at best only partially mobilized in the
context of CBHI. These contradictions,
inconsistencies and conflicts help
explain the inability of CBHI to expand
coverage. Because solidarity was used
as a catch-all phrase, rarely unpacked
in the way we have done in this paper,
stakeholders were able to continue using
the rhetoric of solidarity, despite the lack
of implementation on the ground.
As such, this study raises a number
of previously overlooked policy and
implementation challenges for expanding
CBHI coverage in Senegal, and perhaps
elsewhere. Policy-makers need to engage
in a more rigorous public discussion of
solidarity as regards CBHI and universal
health coverage policy more widely, in
order to move towards policies which both
resonate with and meet the expectations of
the people they aim to serve.
There is a need to reform CBHI so
that it becomes a coherent solidarity
mechanism, which both provides financial
protection and resonates with local
values concerning all four dimensions of
solidarity. This may involve government
subsidies to cover premiums of all or
of parts of the population. However,
the possibility of low cost-effectiveness
of premium subsidies as compared with
direct payments to providers casts doubt
on this policy option. Therefore, echoing
previous analyses of market-oriented
health sector reforms37 and consumer-led
financing,38 alternative or complementary
public sector and/or supply-side financing
policies may be needed in order to
ensure financial protection from the cost
of ill health. These may include health
financing mechanisms which are more
26
integrated into government systems of
social welfare.39
From a methodological perspective,
the results suggest that studying values
among stakeholders in multiple case
studies can greatly enhance research
into health financing. Adopting a similar
methodological approach may be a useful
complement to traditional health systems
analysis to understand the challenges
faced by not only CBHI but universal
health coverage policies more widely. p
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Art 5).
5
Financing flows through
private providers of HIV
services in sub-Saharan
Africa
Sean Callahan, Sharon Nakhimovsky
Abt Associates, Washington, DC, United States of America
Corresponding author: Sean Callahan, e-mail: [email protected]
O
SUMMARY—Fully leveraging the potential of
private actors to manage health finance and
provide health services is an important strategy for
sustaining national HIV responses and increasing
access to services in developing countries. Authors
used health and HIV resource tracking data from
Côte d’Ivoire, Kenya, Malawi and Namibia to
assess the sustainability of these countries’ HIV
financing and compare the magnitude and origin
of resources flowing to private HIV providers,
paying particular attention to the financial burden
falling on people living with HIV (PLHIV). Findings
indicate that the HIV responses in all four countries
face sustainability challenges as well as a gap
in financial coverage for PLHIV seeking care at
private providers. Despite donors’ stated interests
in private sector engagement and public-private
partnerships, findings also indicate that very little
of their funding actually reaches those providers,
which are instead largely financed by PLHIV paying
out-of-pocket. In light of these findings, donors
and government actors in these countries should
consider ways of making private providers of HIV
services a more integral part of publicly led efforts
to build a sustainable, country-driven response to
the HIV epidemic.
ver the past decade, the public
health community has made
significant strides in tackling
the global HIV epidemic. Donor-funded
programmes, including the President’s
Emergency Plan for AIDS Relief
(PEPFAR) and the Global Fund for
AIDS, Tuberculosis and Malaria have
marshalled unprecedented resources
to combat the disease. Supplementing
domestic funding with this support,
national HIV programmes helped
12.9 million people access life-saving
antiretroviral therapy (ART) by the end
of 2013. While the number of PLHIV
increased from 32.1 million in 2005 to 35
million in 2013, rates of new infections
and AIDS-related deaths have declined.1
Much remains to be done. The vast
majority of PLHIV live in low- and middleincome countries, and almost two thirds
face barriers to accessing ART services.1
Moreover, just as HIV funding needs rise
with the number of PLHIV receiving
routine care, donor funding has stagnated
in many of these countries, forcing their
governments to develop innovative ways
to raise domestic financing and increase
efficiency. Engaging private hospitals
and clinics into the government’s HIV
response can increase access to ART
and other HIV services in a sustainable
way. Private hospitals and clinics alone
make up half of the health facilities in
many sub-Saharan African countries and
can be the preferred option for PLHIV
receiving care for reasons concerning
privacy and convenience, among others.2
Recognizing the potential for leveraging
the resources private providers offer
to increase access to HIV care, many
sub-Saharan governments have pursued
public-private partnership opportunities,
for example, subcontracting out delivery
of key services, strengthening referrals
between public and private facilities, and
using government funds to pay for care
at private facilities.
In order to develop effective partnerships
with private providers, governments must
understand the role these facilities can
play in the HIV response. However, in
many countries governments have little
information to foster such understanding.
This article attempts to help address this
knowledge gap by tracing the flow of
spending on HIV from the sources of
financing, through financing agents, and
finally to private providers of HIV goods
and services in four sub-Saharan African
countries. By highlighting these flows,
authors seek to demonstrate the scope
and magnitude of the private sector’s
contribution to the HIV response as
well as identify potential ways donors
and governments can better leverage
resources these private providers offer.
Methodology
Data on past HIV spending can support
efforts to understand the private sector’s
role in the HIV response and improve the
sustainability of HIV programmes.3 As
part of the USAID-funded Strengthening
Health Outcomes through the Private
Sector (SHOPS) project, authors used
HIV spending data compiled according
to national health accounts (NHA) –
the global standard for health resource
tracking. National health accounts track
the flow of health spending in a country.
This flow begins with an entity that
provides the funds (source), which may
be the ministry of finance, employers
(parastatals and private sector), an
external partner or household, before
moving to an agent (manager), such as
the ministry of health, health insurance
27
Table 1. Selection criteria for sample countries
Criteria
Total population (2010)
Côte d’Ivoire
Kenya
Malawi
Namibia
19 378 000
40 513 000
15 370 000
2 283 000
Lower middle
income
Low income
Low income
Upper middle
income
Geographic location
West Africa
East Africa
Southeast Africa
Southern Africa
Adult HIV prevalence
No. of PLHIV on ART
2.7%
120 000
6%
690 000
10.3%
510 000
14.3%
120 000
Income group (World Bank)
programmes, or a non-governmental
organization (NGO). Managers spend
the funds at health-care providers.
National health accounts identify the
amount of funds spent at each type
of provider (public or private, health
clinic or hospital), as well as the types
of health goods and services consumed
there. While the general NHA tracks
total health spending, HIV subaccounts
detail spending on HIV.4 Authors selected
four sub-Saharan African countries (Côte
d’Ivoire, Kenya, Malawi and Namibia) to
include in this analysis because they have
high quality NHA and HIV subaccounts
data, represent a range of geographic
regions, socioeconomic levels and have
high numbers of PLHIV and HIV
prevalence rates.
Results
Côte d’Ivoire
In 2008, Côte d’Ivoire’s HIV response
was highly dependent on international
donors. Some 87% of the country’s
HIV spending originated with donors
– a ratio that is 74 percentage points
higher than donors’ share of general
health expenditures. In contrast, the
Côte d’Ivoire Government provided only
7% of HIV funds. Households, private
businesses and other private entities
contributed the smallest proportion of
HIV funds, amounting to 5% of HIV
expenditure combined (Figure 1).
While donor and government spending
together effectively subsidized HIV care,
findings suggest some gaps in financial
coverage for PLHIV remain. At an
aggregate level, PLHIV out-of-pocket
expenditure accounted for only 3% of
HIV spending – much lower than in
the health sector overall, where 66% of
expenditures were spent out-of-pocket.
However 74% of out-of-pocket spending
on HIV occurred at private pharmacies
and health facilities indicating that PLHIV
still purchase HIV goods and services in
the private sector despite the availability
of free services in the public sector.
Only 5% of all HIV spending in 2008
went to for-profit providers. Donors
allocated some funding for HIV to
for-profit hospitals and clinics through
NGOs. Although NGOs accounted for
99% of spending at for-profit facilities,
this amount was only 2% of all NGO
spending on HIV. No funding from the
Côte d’Ivoire Government went to forprofit facilities.
Figure 1. Source and agents of HIV financing in Côte d’Ivoire (2008)
For this analysis, the private health
sector includes for-profit and non-profit
actors. Notwithstanding variation across
countries, for-profit actors included
private health insurance companies,
privately owned medical facilities,
companies with employee health
programmes and private pharmacies.
Non-profit actors included faith-based
organizations, charities, NGOs, nonprofit health facilities and communitybased organizations.
Cross-country analysis was limited
by some variability in data collection
methods across the selected countries,
most particularly in their approach to
estimating out-of-pocket spending by
PLHIV, as well as the limited number of
quality NHA studies completed. Despite
these limitations, these NHA data still
offer the most accurate estimation of
health expenditure flows in developing
countries and provide valuable
information to inform decisions about
resource allocation and strategic planning,
increase transparency, track progress
toward spending goals, and strengthen
civil society’s advocacy efforts.
28
Source: USAID SHOPS Project led by Abt Associates (2014)
Kenya
Between 2006 and 2010, Kenya’s HIV
response became less dependent on
donor funding and saw insurance
coverage of HIV services increase. In
2010, donors accounted for 51% of
HIV funding, proportionately greater
than their share of general health funding
(35%) but 19 percentage points lower
than in 2006 (Figure 2). During the same
period, insurance spending – including
both private insurance companies
and the National Hospital Insurance
Fund (NHIF) – increased tenfold as
coverage spread and HIV services were
incorporated into insurance schemes’
benefit packages. Despite donor and
government subsidies and increased risk
pooling through insurance, out-of-pocket
spending by PLHIV accounted for 19%
of HIV spending in 2010.
About a quarter of all HIV spending
went to private for-profit facilities in
Kenya in 2010 – significantly more than
in most sub-Saharan African countries.
Financiers of this funding included the
NHIF and private insurance, together
accounting for a third of all HIV
resources spent at these facilities (US$
16.4 million). Insurance mechanisms
spent an additional US$ 6.4 million for
HIV services at not-for-profit facilities.
As the Kenyan Government accounts for
approximately 11% of funding managed
by private health insurance, it is likely
that government funds were spent at
for-profit facilities. PLHIV were the main
financier of HIV services at for-profit
facilities in 2010, accounting for 71% of
all facility resources. PLHIV spending
at for-profit facilities also accounted for
more than half (54%) of their out-ofpocket spending.
Malawi
As in Côte d’Ivoire, Malawi’s HIV
response is highly dependent on donors.
In 2009, donors accounted for 83% of
the US$ 181.5 million spent on HIV,
which was 22 percentage points greater
than their share of general health funding.
Between 2003 and 2009, growth in donor
spending on HIV increased at a much
greater rate than growth in domestic
financing. This increase exacerbated
Malawi’s reliance on donor HIV funding
yet effectively expanding the reach of the
HIV response by funding more services
for PLHIV. Even though increased donor
funding along with government HIV
funding kept out-of-pocket payments
by PLHIV at 4% of HIV financing in
2009, the absolute amount of out-ofpocket payments by PLHIV increased by
300% between 2003 and 2009, even when
accounting for inflation. Private actors
only provided 3% of HIV spending in
2009, and managed about 7% (Figure 3)
HIV spending at non-profit facilities
increased from US$ 1.8 million in 2003
to US$ 17.2 million in 2009 and became
increasingly reliant on donors. Some
76% of spending at facilities associated
with the Christian Health Association
of Malawi (CHAM) in 2009 came from
donors, an increase of 48 percentage
points since 2003. Donors channelled
funding for HIV to non-profit (primarily
CHAM) facilities through three different
routes: public agencies, donors and
international partners, and direct
payments to CHAM. Between 2003 and
2009, spending on HIV at for-profit
facilities increased from US$ 1.0 million
to US$ 3.5 million. Very little of this
funding originated with the Government
of Malawi or donors. Despite donor
and government subsidies, growth in
HIV spending at for-profit facilities
primarily came from PLHIV spending
out-of-pocket. This trend shows that
PLHIV purchased HIV goods and
services at for-profit facilities despite the
availability of subsidized and free care at
public facilities and indicates that there
is possibly a growing gap in financial
coverage for PLHIV.
Figure 2. Source and agents of HIV financing in Kenya
(2010)
Figure 3. Source and agents of HIV financing in Malawi
(2009)
29
Namibia
A middle-income country with high
prevalence of HIV, Namibia has a highly
donor dependent HIV response in an
otherwise domestic-funding driven health
system. Specifically, in 2009, donors
accounted for 51% of HIV funding in
Namibia, 29 percentage points more
than their share of general health
spending (Figure 4). The Government
of Namibia provided 45% of total HIV
expenditures. Donor and government
spending effectively subsidized health
care, as indicated by low levels of outof-pocket spending on health (6% of
total health spending) and HIV (3% of
total HIV spending). Private business
spending at private health insurance
companies accounted for less than 1%
of HIV spending.
Of the US$ 130.9 million spent on
HIV at all health facilities in 2009, the
majority (88%) went to public facilities,
while for-profit facilities only accounted
for 7%. For-profit facility HIV funds
came primarily from PLHIV (76%),
public employee insurance (20%) and
private insurance companies (4%). Public
employee insurance, which is funded by
the government (85%) and household
contributions (15%), is also one of
the main sources of funding at private
pharmacies (51%). It is the only channel
through which government money reaches
private health facilities. Most HIV funds
managed by private insurance companies
were spent at for-profit facilities (65%) or
private pharmacies (31%). Around 40% of
out-of-pocket spending on HIV occurred
at for-profit facilities, indicating that
PLHIV still use private facilities despite
the availability of free and subsidized
services in the public sector. In contrast,
NGOs, which were the second largest
financing agent for HIV spending (29%),
spent most of their HIV funding (94%) at
public health programmes and providers
of health-care administration.
Figure 4. Source and agents of HIV financing in Namibia (2009)
30
Discussion
Even though many governments have
increased funding allocations for HIV
programming, most of the countries
in this analysis still rely heavily on
donor funding. Across the board, all
four countries saw donors contribute
a greater portion of funding for HIV
than for general health. In Kenya, even
though public and private entities have
increased their spending on HIV, donors
still accounted for more than half of
HIV funding in 2010. Donors provided
87% of Côte d’Ivoire’s HIV expenditures
in 2008, but only 13% of general health
spending. Between 2003 and 2009, HIV
spending in Malawi increased by over
560%, largely resulting from increased
focus on HIV by donors who provided
83% of HIV funds in 2009. Similarly,
more than half of Namibia’s HIV funding
came from donors in 2008.
Increased donor investment helped scale
up prevention programmes and get more
PLHIV on treatment. Donor dependency,
however, undermines the sustainability
of these programmes and leaves them
vulnerable to changes in donor priorities.
These findings highlight the importance
for governments and donors to increase
country ownership and link funding to
long-term sustainability strategies for
countries’ HIV programmes. PEPFAR,5
the Global Fund,6 the World Bank7 and
other major donors have all identified
private sector engagement and publicprivate partnerships as a key strategy
to expand access to HIV services in
a sustainable, country-driven way.
Example efforts include engaging private
companies for workplace programmes,
contracting providers to deliver HIV
services, and supporting the development
of affordable, comprehensive prepaid
health financing mechanisms. However,
results of this analysis show that real
support for private sector development
may not match these stated intentions.
For example, in Namibia very little donor
money actually made it to private facilities;
in Malawi a much larger percentage of
donor funding reached private (mainly
non-profit/CHAM) facilities. Going
forward, donors should monitor how
funding for HIV treatment is spent at
the facility level to ensure that their
spending aligns with their stated strategic
intentions.
Incorporating private providers and
the HIV services they provide into
public HIV programmes or insurance
mechanisms may help donors and
governments manage financial risk to
households. In all four countries, outof-pocket payments by PLHIV as a
percentage of total HIV spending were
lower than contributions of households
for general health. These findings indicate
that donor and government investments
have helped reduced the burden on
PLHIV to finance their HIV care but
that more needs to be done, especially
to protect poor PLHIV from financial
hardship. Out-of-pocket payments tend
to be highest at private for-profit facilities,
which are often clients’ preferred choice
despite the availability of subsidized
services in public sector facilities in all
four countries. In Kenya, out-of-pocket
spending by PLHIV at for-profit facilities
decreased as a share of spending at forprofit facilities with increased spending
by insurance mechanisms, but still
accounted for the majority of HIV
spending at these facilities. In Malawi,
out-of-pocket spending by PLHIV at
for-profit facilities grew from 32 to 64%
of the HIV expenditures at these facilities
between 2003 and 2009.
Integrating private for-profit facilities
comprehensively within government
and donor-sponsored HIV programmes
could ensure more consistent financial
risk protection to PLHIV regardless of
where they prefer to seek care. Namibia
has already demonstrated one way to
do this. In 2008, more than half of
HIV spending by government employee
insurance programmes occurred at forprofit facilities.
Another strategy is to promote health
insurance coverage of HIV services,
particularly in countries like Namibia
and Kenya with a growing, vibrant
health insurance market. NHA and
insurance coverage data show the need
for affordable health insurance products.
Private insurance in Kenya managed
more HIV spending than NHIF in 2010,
but covered almost two million fewer
people. Those covered are primarily
formal sector workers, indicating that
insurance-managed funding benefits
a small, wealthy subset of the Kenyan
population.2,8 To mitigate this inequity,
health insurance companies can develop
low-cost products that are affordable for
a greater percentage of the population.
Governments and donors may need to
work together to promote risk-pooling
mechanisms for PLHIV. Tracking
how these new financing mechanisms
decrease the financial burden on PLHIV
will inform further reforms to improve
coverage of PLHIV in insurance schemes.
Stakeholders should also ensure that
risk-pooling mechanisms are reliable and
efficient to reduce administrative burdens
on both payers and providers.
More regular and accurate estimates of
HIV service use and spending at private
facilities can inform strategies to engage
the private sector. Key to developing
effective strategies is accurate data. More
high quality trend data in all countries
can also strengthen the power of future
analysis to track the development of HIV
financing flows through private providers.
Health sector stakeholders should make
a concerted effort to systematically
track resource flows through the private
sector to more accurately measure its
contribution to the HIV response and
incorporate it into strategic planning.
Conclusions
Private providers of HIV services are
important partners in national HIV
responses. In many developing countries,
their size and geographic spread can help
reduce geographic barriers to accessing
care, and PLHIV often prefer them given
shorter wait times and perceived greater
discretion. This study argues that greater
integration of these partners into the
government-led HIV responses in Côte
d’Ivoire, Kenya, Malawi and Namibia can
support efforts to sustainably increase
access to services and improve financial
protection of vulnerable populations. p
References
1. HIV/AIDS Fact sheet No. 360. WHO 2015. Available from:
http://www.who.int/mediacentre/factsheets/fs360/en/
[accessed 10 June 2015].
2. Barnes J et al. Kenya Private Health Sector Assessment.
Private Sector Partnerships-One project. Bethesda, MD:
Abt Associates Inc 2009.
Barnes J et al. Ivory Coast Private Health Sector
Assessment. Strengthening Health Outcomes through
the Private Sector project. Bethesda, MD: Abt Associates
Inc 2013.
3. The methodology for conducting NHA was updated in
2011. The NHA data used in this analysis were generated
before the update.
4. HIV/AIDS NHA subaccounts capture both health and nonhealth related HIV/AIDS spending. HIV spending estimates
used in this analysis only include spending on activities
that aim to improve, maintain or prevent deterioration of
health. They do not include non-health programmes such
as those focused on orphans and vulnerable children.
5. PEPFAR. PEPFAR Blueprint: Creating an AIDS-free
generation. Washington, DC: PEPFAR 2014. Controlling
the epidemic: Delivering on the promise of an AIDS-free
generation. Washington, DC: PEPFAR 2012.
6. The Global Fund to Fight AIDS, Tuberculosis and Malaria.
The Global Fund Strategy 2012–2016: Investing for Impact.
Geneva: The Global Fund 2012.
7. World Bank. The World Bank’s Global HIV/AIDS Program of
Action. Washington, DC: World Bank 2005.
8. Joint Learning Network for Universal Health Coverage.
See: www.jointlearningnetwork.org [accessed 11 June
2015].
General references
Government of Kenya and Health Systems 20/20. Kenya
National Health Accounts 2005/2006 and 2009/2010. Health
Systems 20/20 project. Bethesda, MD: Abt Associates Inc 2009
and 2011.
Government of Namibia. Health and HIV/AIDS Resource
Tracking: 2007/08 and 2008/09. Health Systems 20/20 project.
Bethesda, MD: Abt Associates Inc 2010.
IMF. Statement at the Conclusion of an IMF Mission to Malawi.
International Monetary Fund 2013.
Ivory Coast Ministry of Health and Public Hygiene. Comptes
Nationaux de la Sante République de Côte d’Ivoire. Health
Systems 20/20 project. Bethesda, MD: Abt Associates Inc 2010.
Ministry of Health, Malawi. Malawi National Health Accounts
2002–2004, 2006/07, 2007/08 and 2008/09 with subaccounts
for HIV and AIDS, Reproductive and Child Health. Lilongwe:
Department of Health Planning and Policy Department 2007
and 2012.
Sangare KA, Coulibaliy IM, Ehouman A. Seroprevalence of HIV
among Pregnant Women in the Ten Regions of the Ivory Coast.
Santé 1998; 8(3):193–198.
Sulzbach S, De S, Wang W. From Emergency Relief to
Sustained Response: Examining the Role of the Private Sector
in Financing HIV/AIDS Services. Bethesda, MD: Private Sector
Partnerships-One project, Abt Associates Inc 2009.
UNAIDS. See: http://www.unaids.org/en/dataanalysis/
datatools/aidsinfo/ [accessed 11 June 2015].
USAID. Namibia: Engaging the Private Sector to Achieve
Priority Health Goals. SHOPS project. Bethesda, MD: Abt
Associates Inc 2012.
World Bank. World DataBank World Development Indicators.
Washington, DC: World Bank 2014.
Acknowledgements
The authors acknowledge the financial support of USAID/
PEPFAR in funding this research. The authors thank Caroline
Quijada, Ilana Ron, Hailu Zelelew, Elizabeth Corley and
Jennifer Mino-Mirowitz for their technical support, and Chloe
Revuz and Eric MacDicken for their support in designing
infographics for this analysis.
31
6
Early evidence from
results-based financing
in rural Zimbabwe
Frank van de Looij,i Dudzai Mureyi,ii Chenjerai Sisimayi,iii Jaap Koot,iii
Portia Manangazira,iv Nyasha Musuka,iv
Corresponding author: Frank van de Looij, e-mail: [email protected]
D
ue to economic turmoil in the
last decade, government funding
to the public health system
in Zimbabwe reduced considerably.
As a result, many health-care workers
emigrated or sought employment in other
sectors, the infrastructure dilapidated
and health indicators deteriorated.
Maternal mortality rose from 390 to 790
per 100 000 live births.1 Out-of-pocket
expenditure as a percentage of total
health expenditure rose to 50.4%.2
SUMMARY—Results-based financing (RBF)
is an innovative approach to health system
financing which pays providers for verified
outputs. In July 2011, through a World Bank
grant, Zimbabwe commenced an RBF project to
improve utilization of quality maternal, neonatal
and child health (MNCH) services. This article
discusses its early results. A statistical analysis of
intervention districts and control districts shows
that RBF districts demonstrate higher increases
in utilization levels for the MNCH services than
control districts. Month-on-month growth rates
for antenatal care, perinatal referrals and growth
monitoring are statistically significant after the
intervention, whilst they were not before the
intervention and no significant trend was found
in control districts. Qualitative study provides
insight in the mechanisms through which RBF
contributed to better performance: the use
of contracts, increased autonomy of health
facilities, increased community involvement,
intrinsic motivation of health-care workers,
existence of a reliable health information system,
abolishment of user fees, improved supervision
of health facilities, separation of functions, and
the Government of Zimbabwe’s results-based
management (RBM) policy.
32
However, since 2009, the Ministry of
Health and Child Care (MoHCC) has
made considerable progress in revitalizing
the health system and its policy has
gradually moved from organizing
emergency service delivery to health
system strengthening, as shown by the
Health Investment Case3 and its National
Strategic Plan.4 Through the Zimbabwe
Agenda for Sustainable Socio-Economic
Transformation (ZIMASSET) and the
country’s new strategic plan for economic
transformation anchored within resultsbased management (RBM) principles, the
government has committed to strengthen
the health system and improve key health
indicators and has projected a cumulative
growth of 22.5% in the health sector
between 2013 and 2018.5
To support the MoHCC in its efforts to
further strengthen the health system, the
World Bank committed a grant of US$ 15
million to a results-based financing (RBF)
project aimed at increasing utilization
of quality maternal, neonatal and child
health (MNCH) services, primarily
through the abolishment of user fees.
The RBF project pays health facilities –
rural health centres (RHCs) and district
hospitals – for outputs/results rather than
inputs. The larger the volume of output
(high utilization), the larger the payment
i Cordaid, The Netherlands
ii Cordaid, Zimbabwe
iiiIndependent public health consultant
ivMinistry of Health and Child Care, Zimbabwe
a facility receives. This is the hallmark of
RBF, where income is linked to levels of
output.
Abolishment of user fees and thus
increased service utilization is the primary
goal of the RBF project in Zimbabwe. To
this effect, RBF payments compensate for
income forgone due to the abolishment of
user fees. Motivating providers to increase
output and improve service delivery is the
secondary goal of RBF. For this purpose,
a portion of the RBF payments can be
invested in improving providers’ working
conditions and paying staff incentives. In
Zimbabwe RBF started as a two-district
pilot in July 2011 and was scaled up in
March 2012 to 18 rural districts covering
a total population of 4.1 million.
The rural public health-care system in
Zimbabwe follows a typical district healthcare model with a district hospital being
a referral centre, and RHCs providing
primary health care. Each district is
managed by a district health executive
(DHE). The DHEs and district hospitals
in a given province are in turn supervised
by a provincial health executive (PHE).
For general oversight over the RBF
project, a multi-stakeholder RBF National
Steering Committee (NSC) and district
steering committees (DSCs) in each of the
implementing districts were established.
Health facilities are contracted to offer
a set of RBF-incentivized services
and DHEs/PHEs are contracted to
supervise RHCs and district hospitals.
Community-based org anizations
(CBOs) are contracted for community
sensitization activities and assessment of
user satisfaction. A National Purchasing
Agency (NPA) executes specific RBF
activities, i.e. contracting all the actors
in the project (health facilities, DHEs/
PHEs and CBOs), verification of results
and disbursement of payments to the
contracted parties for verified results. In
Zimbabwe the Catholic Organization for
Relief and Development Aid (Cordaid),
was contracted by the World Bank
(according to the Bank’s contracting
procedures) to perform the NPA tasks in
Zimbabwe. This is a temporary measure,
as the Government of Zimbabwe, being
in arrears, could not be directly engaged
by the bank. An independent agency, the
University of Zimbabwe, is contracted to
perform counter verification, i.e. verifying
whether the NPA, DHEs, PHEs and
CBOs are correctly performing their
tasks as verifiers and supervisors. The
separation of functions of purchaser,
provider, verifier, counter-verifier, client
tracing, quality assessor and regulator, is
meant to ensure integrity at each stage of
the RBF cycle.
Contracted health institutions, which need
to meet minimum criteria before being
contracted, receive a quarterly payment
from the NPA based on the quantity of
RBF-incentivized services provided and
the quality of these services. The vast
majority of these incentivized services
are related to MNCH. However, to avoid
a focus on MNCH only, to the detriment
of other clinical services, “outpatient
consultation” (first visit only) was added
as an incentivized service too. Inequity
is mitigated by awarding additional
‘remoteness’ bonuses to facilities which
serve relatively geographically inaccessible
populations – to top up their earned RBF
incomes.
Health facilities, together with their
health centre committees (HCCs), write
annual plans which are approved by
the DHE (or PHE for hospitals). RBF
health facilities hold their own deposit
accounts and are autonomous in how they
spend the money earned for purposes
that are consistent with the contents of
their operational plans (plans they make
annually and that are approved by the
DHE). Since January 2013, facilities can
use 25% of their earnings to award staff
bonuses.
The aim of this article is to describe and
attempt to explain, the effects of RBF in
rural Zimbabwe.
Methods
The RBF project in Zimbabwe runs in
18 districts across 8 provinces. However,
for evaluation purposes, only two RBF
districts per province were chosen and
matched with two non-RBF (control)
districts of similar socio-economic,
geographic and health utilization
characteristics, thus creating 16 pairs of
districts for comparison. Intervention
(RBF) and control districts were compared
for differences in service utilization trends
for both RBF-incentivized and nonincentivized services. The control districts
continued to receive similar support from
government, vertical programmes and
donors as they received before. Data for
the comparison of the trends in service
utilization for RBF-incentivized and
non-incentivized services were obtained
from the health management information
system from March 2011 to June 2013.
Descriptive statistics (percentage
increases) were used for analyses of
patient volumes. In addition a segmented
linear regression was done and the time
series was adjusted for auto-correlation.6
The findings from the statistical analysis
were triangulated with findings from
qualitative research, which derived data
from:
Document reviews of relevant policy
documents, (training) manuals and
progress reports;
Financial data from the NPA on
total programme spending and
disbursements to facilities;
Semi-structured interviews with
officials from one hospital and two
randomly selected health centres in
each of the study districts (RBF and
control districts), as well as the DHEs,
DSCs and PHEs;
Focus group discussions with at least
four HCCs and four CBOs in each
district; and
Stakeholder interviews with officials
from MoHCC, NSC, NPA and other
relevant parties, including international
donor organizations present in
Zimbabwe.
Qualitative research took place in
February and March 2013. All findings
To discourage facilities from focusing
merely on volume of services, the
quarterly payments to facilities also take
quality scores into account. Each quarter,
DHEs and PHEs conduct supervisory
visits to RHCs and district hospitals
respectively and use a standardized quality
checklist to assess quality indicators and
award scores. CBOs also conduct surveys
among health service users and their
responses determine the client-perceived
quality score for each facility. A facility’s
overall quality score is then calculated
from both the CBO score and DHE/
PHE score and determines the amount
in quality bonus a facility accrues, on top
of the service quantity earnings.
33
Moreover, the study found indications
that the reliability of data entered into the
national health management information
system (HMIS) improved in RBF districts
(Figure 2). In the RBF scheme, facilities
incur deductions in payments when
there is a discrepancy between the data
they declare to the national HMIS and
the data which are verified by the NPA.
Income forgone as a result of these
discrepancies also decreased in the RBF
districts (Figure 3).
Quality of services was only measured
in the RBF districts and data collection
only started at the beginning of the
34
Change in volumes
(% points; n=398)
44.6%
0.8%
19.9%
12.5%
HIV VCT in ANC
3.5%
-12.2%
ARVs to HIV + pregnant women (PMTCT)
5.6%
37.1%
Tetanus TT2+
7.7%
7.7%
Syphilis RPR test
18.4%
-1.2%
IPT (x 2 doses)
21.9%
2.9%
Normal deliveries
20.2%
17.6%
High-risk perinatal referrals
78.1%
11.0%
Family planning, short-term methods
33.0%
12.4%
Primary course completed
-18.7%
-6.5%
Growth monitoring
96.7%
19.2%
Figure 1. ANC 4+ visits, in RBF and control districts
HMIS RBF
HMIS Non RBF
14 000
12 000
10 000
8 000
6 000
4 000
2 000
May 13
Mar 13
Jan 13
Nov 12
Sep 12
Jul 12
May 12
Mar 12
Jan 12
Nov 11
0
Sep 11
Table 2 shows that there is a significant
change in volume of normal deliveries as
a result of the intervention. After the start
of the intervention a significant positive
trend was found for ANC 4+ visits,
high-risk perinatal referrals and growth
monitoring, whereas no significant trends
were found in the control districts. Finally,
one can observe significant positive
trends before the intervention for OPD
new consultations, syphilis RPR test and
IPT2. These trends are not significant
after the intervention.
Change in volumes
(% points; n=387)
ANC 4+ visits
Jul 11
Table 2 provides insight into the statistical
significance of the findings. It compares
growth rates (month-on-month volume
changes) of the different indicators
before and after the intervention and
shows the sudden volumes changes as a
result of the intervention.
January 2012–June 2013
Control districts
OPD new consultations
May 11
For the majority of indicators the
analysis revealed that service utilization
in the RBF-districts has increased since
March 2012. Compared with non-RBF
districts, RBF districts show relatively
higher growth rates (Table 1). Exceptions
are prevention of mother-to-child
transmission (PMTCT) and primary
immunization course completed. A
graphical presentation of the trends also
shows increased growth rates in RBF
districts after the start of the intervention.
This is particularly evident for antenatal
care (ANC) visits (Figure 1).
January 2012–June 2013
RBF districts
Indicator
Mar 11
Results
Table 1. Comparison between trends in RBF and control districts for selected
incentivized indicators
Count
were discussed with relevant stakeholders
during a national workshop and joint
conclusions from the assessment were
arrived at.
Source: Zimbabwe National HMIS
Table 2. Month-on-month increase before and after the intervention (March
2011 to June 2013)
Indicator
RBF
ANC 4+ visits
HIV VCT in ANC
Tetanus TT2+
Syphilis RPR test
IPT2 (2 doses)
Normal deliveries
Growth monitoring
Non-RBF
ANC 4+ visits
HIV VCT in ANC
Tetanus TT2+
Syphilis RPR test
IPT2 (2 doses)
Normal deliveries
Growth monitoring
Pre-slope
P-value
Intervention
P-value
Post-slope
P-value
85.6
1115.2*
125.5
24.3
298.6*
252.4*
-18.9
2.9
-185.3
-3.2
-222.8
0.129
0.007*
0.107
0.903
<0.01**
0.01*
0.522
0.767
0.892
0.977
0.875
-78.8
7720.8
758.6
535.9
1481.8
-140.1
738.2*
-156.8
-3055
-436.6
9144.9
0.858
0.809
0.272
0.618
0.078
0.76
0.01*
0.089
0.702
0.667
0.459
160.2**
127.5
-43.7
-5.9
-16.4
22.6
27.7
50.1**
776.2
-46.6
2412*
<0.01**
0.96
0.379
0.968
0.784
0.629
0.158
<0.001**
0.445
0.529
0.016*
92.4
4745.2*
67.6
-44.3
268.1
299.7**
-30.4
2.2
-135
-48.9
426.1
0.139
0.019*
0.197
0.812
<0.01
<0.001**
0.406
0.693
0.892
0.461
0.497
-452.8
12427
-469.5
-479.5
159.32
-445.4
-207.4
-18.3
-5281.5
78.3
1480.9
0.39
0.468
0.32
0.67
0.842
0.093
0.525
0.72
0.531
0.896
0.794
9.6
437.4
-10
40.3
-18.8
-13
45.8
1.98
271.8
23.2
247.8
0.815
0.727
0.763
0.769
0.752
0.484
0.064
0.595
0.687
0.586
0.54
Pre-slope/post-slope: month-on-month changes in volumes before or after the intervention, if p-value <0.05 then changes significant
either positive (+ve coefficient) or negative (-ve coefficient)
Intervention: the change in level, sudden increase (again check for significance)
*= P<0.05
**= P<0.01
Figure 2. Differences between syphilis RPR tests done during first ANC visit
which were declared in the HMIS system and which were verified by the NPA,
in the RBF districts
HMIS RBF
Verified RBF
12 000
Count
10 000
8 000
6 000
4 000
2 000
May 13
Mar 13
Jan 13
Nov 12
Sep 12
Jul 12
May 12
Mar 12
Jan 12
Nov 11
Sep 11
Jul 11
May 11
Mar 11
0
Source: Zimbabwe National HMIS and the Cordaid Zimbabwe RBF database
Figure 3. Lost revenue due to reporting errors
Trendline
Jun 13
May 13
Apr 13
Mar 13
Feb 13
Jan 13
Dec 12
Nov 12
Oct 12
Sep 12
Aug 12
Jul 12
Jun 12
May 12
Apr 12
35
30
25
20
15
10
5
0
Mar 12
(%) Percentage
Lost revenue due to reporting errors
Figure 4. Malaria cases treated among children older than five, in RBF and
control districts
Series 1
Dec 12
Oct 12
Nov 12
Sep 12
Jul 12
Aug 12
Jun 12
May 12
Apr 12
Feb 12
Mar 12
Jan 12
Dec 11
Nov 11
Oct 11
Sep 11
Aug 11
Jul 11
Jun 11
May 11
Apr 11
120
100
80
60
40
20
0
Mar 11
Per 10 000 Population
Series 1
Figure 5. Acute respiratory infection cases among children older than five, in
RBF and control districts
Series 1
Dec 12
Oct 12
Nov 12
Sep 12
Jul 12
Aug 12
Jun 12
May 12
Apr 12
Feb 12
Mar 12
Jan 12
Dec 11
Nov 11
Oct 11
Sep 11
Aug 11
Jul 11
Jun 11
May 11
Apr 11
350
300
250
200
150
100
50
0
Mar 11
Per 10 000 Population
Series 1
intervention. Therefore no comparison
with control districts or the trend before
the intervention could be made. However,
quality scores show a slight increase since
the start of the intervention in the RBF
districts. The focus group discussions and
interviews confirm the observed quality
increments. Respondents also indicated
that the satisfaction surveys by CBOs
have a strong impact on the attitude
of staff. The direct feedback on their
behaviour (and the financial incentive
related to the CBO score) has sensitized
staff to the importance of client-friendly
behaviour. Waiting times are reported to
have reduced and nurses are perceived as
being more responsive to emergencies.
All health facilities in the RBF districts
have stopped charging fees for MNCH
services, in line with the goals of the
project. This was confirmed through the
CBO client-satisfaction surveys and the
external counter verification. According
to health workers interviewed, subsidies
provided through RBF payments are four
to ten times the amount of previously
received amounts from patient fees for
MNCH services. However, the total
value of salaries, equipment, drug kits
and other contributions from government
and donors still constitutes the majority
of the financing of health institutions.
The RBF subsidies go towards a wide
range of uses: rehabilitation of the
infrastructure, purchase of sundries,
medicines and medical and surgical
supplies, food for patients, payment of
utility bills, hiring of locum and casual
staff, transport and ambulance services.
In some cases the RBF subsidies were
used to pay for staff to obtain training
in certain procedures e.g. insertion and
removal of long-term contraceptive
devices.
As shown in Figures 4 and 5, the trends
in utilization of services, for which no
RBF incentives are provided, show
remarkable similarities between RBF and
non-RBF districts, before and after the
intervention; an indication that the validity
of comparisons between intervention
and control districts is high and that
differences in the performance of the
indicators for which RBF incentives were
awarded are likely due to the incentives.
35
Discussion
The results from the comparisons
between RBF and non-RBF districts
reveal a rising trend in utilization services
in RBF districts. For some MNCH
services (deliveries, ANC, high-risk
perinatal referrals and growth monitoring)
these trends are statistically significant.
In the RBF districts, the reliability of
HMIS data and quality of care increased
since the introduction of RBF. The study
also points at externalities that influence
behaviour of health service providers.
Utilization figures for OPD, syphilis
RPR test and IPT2 show a positive trend
before the intervention in both RBF and
control districts, while this trend is no
longer significant after the intervention.
This may for instance be caused by stockouts of drugs and supplies.
Literature about the mechanisms
through which RBF contributes to
better performance is limited. This is
also referred to as “the black box of RBF
implementation”.7 It is generally imagined
however, that the pecuniary incentives
which are earned by providers and are
contingent and proportional to their
productivity, motivate them to perform
better.8 The qualitative study revealed
practices in RBF districts which are not
being followed in control districts. In this
section, the ways in which these could be
contributing to improved performance
are discussed.
First, because the contracting approach
clarifies what is expected of actors
in terms of results,9 the use of RBF
contracts stipulating the obligations of
the NPA, health facilities, DHEs/PHEs
and CBOs has enabled the DHEs/
PHEs to execute their supervisory
role by removing role ambiguity and
ensures that communities’ opinions
are regularly collected through CBOconducted surveys.
The relative autonomy enjoyed by
health facilities in RBF districts is not
a characteristic of governance in nonRBF districts. With active involvement
of staff and HCCs, RBF facilities take
responsibility for operational planning
and implementation. In the non-RBF
(control) districts, operational planning
was a paper exercise because facilities
had no control over the user fees they
collected; they relinquished them to
the DHE. Due to lack of funding
36
to execute the planned activities, the
same plans are submitted every year.
Facility staff in RBF districts also have
increased (not absolute) autonomy
over procurement. So it is likely that
they are able to demonstrate allocative
efficiency and innovation, by acquiring
supplies which are necessary to solve
specific operational problems at their
particular facilities.
C o m mu n i t y i nvo l ve m e n t h a s
always been a strong aspect of the
Zimbabwean public health system,
premised on the primary health care
concept and philosophy. With RBF
funds, HCCs have been re-activated
and are committed and take ownership
of the health services. In addition,
the patient satisfaction surveys by
CBOs, which were a feature in RBF
districts only, gave communities a voice
and likely motivated health service
providers to take the preoccupations
of the community into account in their
operational planning.
Financial incentives, such as applied
in the Zimbabwean RBF project, have
been argued to crowd out intrinsic
motivation of health workers.
However, achievements in the first
nine months of the scaled up RBF
project in Zimbabwe (March 2012 to
December 2012) must be attributed to
intrinsic motivation of staff and HCCs
since, as alluded to earlier in this paper,
personal incentives for frontline health
workers in RHCs and district hospitals
were only introduced after in 2013.
A major contributing element to
the success of an RBF intervention
concerns the efforts made in relation
to training and capacity building. In
the first two years of the programme
around 10% of the total project budget
was invested in training for national
level decision makers, district staff and
facility staff.
Conclusion
In general, the RBF programme in
rural Zimbabwe has shown positive
intermediate results. It has succeeded
in the removal of user fees for MNCH
services, a finding confirmed through
client satisfaction surveys, as well as
compensating health institutions for
the foregone income. Utilization figures
increased in districts which implemented
RBF, indicating that accessibility has
effectively increased.
While the results are inadequate for a
conclusion regarding the statistical
significance of the overall impact of
the RBF project in Zimbabwe, this
research found several elements only
prevalent in the intervention districts,
that may have contributed to the positive
results in service utilization and quality
improvements in RBF districts since the
project commenced. These are:
Use of contracts to clarify what is
expected of each actor for payments
to be made;
Community involvement in the
provision and planning of health
services;
Autonomy for primary health care
facilities in planning and procurement;
and
Intrinsic motivation of staff,
demonstrated by improved utilization
statistics even before personal staff
incentives were introduced in the
project. p
References
1. WHO. Trends in Maternal Mortality: 1990 to 2008. Geneva:
World Health Organization 2010.
2. Zimbabwe National Statistical Agency. Poverty and
Poverty Datum Line Analysis in Zimbabwe 2011/12. Harare:
Zimbabwe National Statistical Agency 2013.
3. Ministry of Health and Child Care. The Health Investment
Case. Harare: Ministry of Health and Child Care 2010.
4. Ministry of Health and Child Care. The National Health
Strategy 2009–2013. Harare: Ministry of Health and Child
Care 2009.
5. Government of Zimbabwe. Zimbabwe Agenda for
Sustainable Socio-Economic Transformation Document.
Harare: Government of Zimbabwe 2013.
6. Lagarde, M. How to do (or not to do) . . . Assessing the
impact of a policy change with routine longitudinal data.
Health Policy Plan 2011; 1–8.
7. Torsvik G. Researching PBF: Time to open the black box.
2013 Available from: http://performancebasedfinancing.
org/2013/06/02/researching-pbf-time-to-open-theblack-box/ [accessed on 11 June 2015].
8. Basinga P et al. Effect on maternal and child health
services in Rwanda of payment to primary health-care
providers for performance: An impact evaluation. Lancet
2011; 377(9775):1421–1428.
9. Eldridge C, Palmer N. Performance-based payment: Some
reflections on the discourse, evidence and unanswered
questions. Health Policy Plan 2009; 24(1):160–166.
7
Piloting a performancebased financing scheme
in Chad: Early results and
lessons learned
Joël Arthur Kiendrébéogo,i Olivier Barthès,ii Matthieu Antony,ii Louis Rusaii
Corresponding author: Joël Arthur Kiendrébéogo, e-mail: [email protected]
P
SUMMARY—The Ministry of Health of the
Republic of Chad decided to introduce a
performance-based financing (PBF) strategy as
a pilot project in eight districts of rural areas,
from October 2011 to May 2013. Based on both
qualitative and quantitative data collected during
the implementation of the scheme, this study
aims to reflect on the early results of the scheme
and draw valuable lessons to inform future scaling
up of the strategy. Despite some methodological
limitations, the results show that overall access to
health services and quality of care improved in the
period considered, even though some indicators
reacted less. These positive results resonate
with the findings of our qualitative interviews
that highlighted changes in ways of providing
care as well as managing health facilities and
regulating the health system. However, results
vary substantially between regions (north and
south) and between facilities. Moreover, the short
duration of the project leaves the sustainability of
these changes in question. In conclusion, our study
stresses the need for evaluations and an evidencebased discussions in order to tailor the design of
PBF scheme to the context, and to better inform
policy-making decisions on PBF schemes, both
at pilot stage and when considering their rollout
nationwide.
erfor mance-based financing
schemes for health facilities
have been attracting increasing
attention in most sub-Saharan Africa
countries and some experts believe that
the strategy could serve as an entry point
to address several structural weaknesses
constraining health systems.1,2 In October
2011 Chad adopted this strategy as a
pilot project for 20 months with the
overarching objective to improve uptake
and quality of health care. Based on the
quantitative data made available by the
PBF data verification process and on
qualitative data collected specifically,
the present study aims to document
the experience gained from field
implementation in order to present the
early results of the scheme and reflect on
the drivers of behavioural change within
facilities and in the wider health system.
This could supply valuable lessons for
a possible future PBF scheme in Chad
and provide a perspective on scaling up.
It could also stimulate critical reflections
from stakeholders and be helpful for
other countries facing similar challenges.
Context
From a health and demographic
perspective, Chad is a complex and
difficult environment. The country’s
health indicators are very low, particularly
those related to maternal, newborn and
child health. According to the Multiple
Indicator Cluster Sur vey (MICS,
2010),3 under five mortality ratio was
175%, infant mortality ratio 106%,
contraceptive prevalence 4.8% and skilled
birth attendance 22.7%. Chad’s maternal
mortality ratio is one of the worst in the
world, at 1 100 per 100 000 live births
in 2010.4
The PBF scheme included four regions
(out of 23 in the country) and eight
districts (out of 72) with two districts
per region. There were a total of nine
district hospitals and 102 primary health
centres (PHCs). The population covered
was estimated at 1 650 000 (Chad’s total
population estimate is 11 million). The
selection of areas for the project was
based on three criteria:5
Districts where maternal and child
health performance indicators were
below the national average;
The poorest districts, according to
national levels of poverty; and
Districts where support from donors
was less important.
Two of the regions were located in the
north of the country (Batha and Guéra,
with 46 PHCs in total) and two in the
south (Mandoul and Tandjilé, with 56
PHCs in total), with completely different
characteristics. Population density is
higher in the south and health facilities,
particularly faith-based ones which are
usually credited with better organization
and management, are more numerous.
By contrast, populations in the north are
more scattered and nomadic, spending
a good part of the year outside their
enumeration area. Moreover, there are
geographical accessibility issues with long
distances from villages to nearest facilities,
with some PHCs being more than 200 km
from the district hospital. Low levels of
education and sociocultural constraints
are also more marked in the north.
The project was designed to be consistent
with the National Health Policy
elaborated for the period 2007–2015,
which identified some problems in
health-care provision, particularly: low
coverage – health facilities in difficult
locations, low technical equipment,
i Centre MURAZ, Burkina Faso
ii Agence Européenne pour le Développement et la Santé (AEDES),
Brussels,
Belgium
ISSUE 20
• SPECIAL
ISSUE ON UNIVERSAL HEALTH COVERAGE
37
lack of infrastructure and maintenance,
poor organization and underfunding
of health services, poor management
and procurement of essential generic
drugs, vaccines and contraceptives, lack
of communication, poor referral system,
low quality of care etc. The PBF project
aimed to directly address some of these
issues to improve service organization
and increase accessibility and quality of
care. The services covered were mainly
within the ‘minimum package of activities’
(essential package of care) of primary
health centres; and the ‘complementary
package of activities’ of district hospitals.
The indicators chosen and purchased
quantitatively (unit prices given) at PHCs
and district hospitals level are shown in
tables 1 and 2.
Health facilities (both PHCs and district
hospitals) were also assessed according to
quality of services, mainly via resources
indicators. There were also indicators
related to: environmental hygiene of health
facilities; confidentiality of consultation
rooms; availability of unexpired and well
stored drugs (including contraceptives
and vaccines) and medical consumables;
availability and functionality of
materials and equipment (thermometer,
sphygmomanometer, stethoscope, delivery
table and boxes, surgery box, sterilizers,
baby scales, measuring rods etc.); records
well completed and tidy; accurate filling
of partographs etc. Regulators, especially
regional health management teams and
district health management teams were
also taken into account. They were
assessed by indicators such as: planning
of activities (availability of action plans);
supervision of health facilities; promptness
and completeness in the transmission of
data from health information system;
regular holding of statutory meetings etc.
The project was managed on a daily
basis by an independent performance
purchasing agency (PPA) whose mission
was twofold: implementation of the
project in the pilot areas and ensuring
transfer of skills to the Ministry of Health
to allow it to manage future PBF projects.
In order to avoid conflicts of interest
and to improve verification of results
and transparency, the Chad PBF scheme
strived for a full separation of functions
between key actors:
Fundholder – The Word Bank;
PPA;
38
Table 1. Quantitative indicators
purchased at the PHC level and their
unit prices in Chad PBF pilot scheme
Indicators
Unit price
(US$)*
Indicator
Curative services
New curative consultations for
children over five years (zone A**
and outside zone B***)
0.20
children over five years (zone B)
0.24
children under five years (zone A and
outside zone B)
Table 2. Quantitative indicators
purchased at the district hospital
level and their unit prices in Chad
PBF pilot scheme
Unit price
(US$)*
New curative consultation referred
or with emergency signs seen by a
doctor
2.00
Major surgery
15.00
Minor surgery
4.00
0.30
Eutocic delivery
6.00
Caesarean
20.00
children under five years (zone B)
0.40
Dystocic delivery
10.00
STI cases treated
2.00
Voluntary test for HIV
2.00
Preventative services
Days of hospitalization
1.50
HIV positive pregnant women under
prophylactic ART
10.00
Number of new cases treated with
HAART
10.00
Children preventive consultation
0.20
Pentavalent 3
1.20
Anti-measles vaccination
1.50
Tetanus vaccination (2+)
5.00
Number of patients taking HAART
and followed every six months
12,00
Pregnant woman counselled and
screened positive for HIV and
transferred to district hospital
6.00
Screening for TB by smear positive
8.00
Number of users of modern
contraceptive methods: IUDs and
implants
8.00
Patients counter referral
5.00
Reproductive health
First prenatal consultation
1.20
Third prenatal consultation
6.00
Eutocic delivery
10.00
Number of users of modern
contraceptive methods: new and
former clients
8.00
*Chad uses CFA franc; exchange rate used: US$ 1 = 500 CFA
franc
*Chad uses CFA franc; exchange rate used: US$ 1 = 500 CFA
franc
**Zone A: area located within 5 km of the health facility
***Zone B: area located 5–10 km from the health facility
Regulator – the Ministry of Health
(MoH); and
Providers including health and
supporting staff as well as health
facility management committees.
Methods
This study adopted both quantitative and
qualitative methods for data collection
and analysis. Quantitative data relate
to the period between October 2011
and March 2013 (18 months) and were
derived from the PBF verification
processes, compiled in Chad’s resultsbased financing web portal (www.
fbrchad.org). Quantitative analysis
mainly focused on trends in health
service utilization during that period,
as well as on the quality of health-care
and administrative services. All health
facilities involved in the PBF scheme
were taken into account. Information
for the qualitative component of this
research was collected over one month
(February–March 2013). Qualitative
data were based on a series of key
informant interviews (KII), as well as
focus group discussions (FGD). Key
informants included officials from
the MoH at central and regional level,
district health management teams
(DHMT), district hospitals health
workers and administrative staff, PHCs
staff and their management committees,
and community-based associations. All
DHMT and district hospitals involved
in the project were taken into account
whereas half of the PHCs were
considered and sampled randomly.
Key informants were interviewed with
different questionnaires and data were
collected in three ways:
Face-to-face interviews with 52 heads
of PHCs;
Self-administered questionnaires for
officials from the MoH at central
level (n=1) and regional level (n=24),
for DHMT members (n=29), for
district hospitals health workers and
administrative staff (n=59); and
41 focus group discussions with
PHC management committees and
community-based associations.
(%) Percentage
80
60
40
20
Mar 13
Feb 13
Jan 13
Dec 12
Oct 12
Nov 12
Sep 12
Aug 12
Jul 12
Jun 12
May 12
Apr 12
Mar 12
Feb 12
Jan 12
Dec 11
Nov 11
Oct 11
0
Figure 2. Evolution of monthly coverage rate for assisted deliveries (average
figures calculated from data from all PHCs involved in the project)
Batha and Guera
Mandoul and Tandjile
Global
60
50
40
30
20
10
Mar 13
Feb 13
Jan 13
Dec 12
Oct 12
Nov 12
Sep 12
Aug 12
Jul 12
Jun 12
May 12
Apr 12
Mar 12
Feb 12
Jan 12
Dec 11
Nov 11
Oct 11
0
Figure 3. Evolution of monthly coverage rates for new curative consultations
for under 5 (average figures calculated from data from all PHCs involved in
the project)
Batha and Guera
Global
120
100
80
60
40
20
Mar 13
Feb 13
Jan 13
Dec 12
Oct 12
Nov 12
Sep 12
Aug 12
Jul 12
Jun 12
May 12
Apr 12
Mar 12
Feb 12
Jan 12
Dec 11
Nov 11
Oct 11
0
Figure 4. Evolution of monthly coverage rate for third antenatal visit (average
figures calculated from data from all PHCs involved in the project)
Batha and Guera
Global
60
50
40
30
20
10
Mar 13
Feb 13
Jan 13
Dec 12
Nov 12
Oct 12
Sep 12
Aug 12
Jul 12
Jun 12
May 12
Apr 12
Mar 12
Feb 12
Jan 12
Dec 11
Nov 11
0
Oct 11
The findings show that access to health
facilities increased generally for all
indicators, even if significant differences
were sometimes observed between
facilities. Key indicators selected from
indicators purchased in PHCs are
shown below. For all results the target
population was used as the denominator.
Considering all PHCs involved in the
pilot scheme, the proportion of children
immunized by pentavalent 3 increased
from 50% to 95%, and for vaccination
against measles it rose from 48% to
91% (Figure 1). Facility-based deliveries
(including caesarean sections) increased
from 17% to 40% (Figure 2), whilst
modern contraceptive prevalence rose
from 1.2% to 6.9% (not shown here).
Conversely, some indicators remained
almost stationary, with a noticeable
seasonal effect. That was the case for
new case of curative consultations for
under five in PHCs, which remained
between 40% and 60% on average, with
peaks of 90% to 115% between July and
October, i.e. during rainy season both in
2012 and 2013 (Figure 3). Similarly the
third antenatal visit ranged on average
between 18% and 25% with peaks around
30% to 40% between January and April
both in 2012 and 2013 (Figure 4). In
all cases, results demonstrated a clear
difference between regions, with those
in the south presenting higher indicators
Vaccination anti-measles
100
(%) Percentage
Utilization of health services
Vaccination pentavalent
(%) Percentage
Quantitative results
Figure 1. Evolution of monthly coverage rate for pentavalent and measles
immunization (average figures calculated from data from all PHCs involved in
the project)
(%) Percentage
Notes were taken during interviews
and we gradually noticed saturation of
data, namely the information collected
was less and less new. All interviews
were conducted in French. Data were
complemented by direct observations
in the field as all four authors were part
of the project implementation, and by a
document review, focusing on documents
produced as part of the project, such
as expert reports, quarterly progress
reports, handbook of procedures for PBF
implementation in Chad etc. Qualitative
data were treated and analysed manually,
using a content analysis with an inductive
approach. We used Stata 11 and Excel 2007
to carry out descriptive statistics for the
quantitative data to monitor trends in some
key indicators. The main limitations of the
data available and the analysis processes are
presented in the discussion section.
39
(as shown in figures 2, 3 and 4 where data
have been disaggregated). But it is worth
mentioning that PBF failed to revive
indicators relating to HIV-related services,
which generally were not provided in
PHCs before the PBF scheme.
Quality of care
Quality checklists were developed
to assess quality of care and they
include items such as health facilities
environment and hygiene, cleanliness
of treatment and waiting rooms,
availability and functionality of medical
and technical equipment for care,
sterilization procedures, biomedical
waste management, existence of standard
treatment protocols, proper filling
and management of patient records,
medicines procurement and management
etc. Quality was assessed quarterly by
the DHMTs and the PPA, and points
were given for each item which were then
converted into percentage scores. Over
the pilot duration PHCs were assessed
for quality five times and the average
score, including all facilities, increased
from 42% (at first verification round) to
67% (at the last one) as shown in Figure 5.
However, these aggregate numbers hide
huge disparities between facilities, with
quality scores ranging from 33.16% to
92.74% in the last quarter when PHCs
Figure 5. Evolution of quality scores in PHCs
60
Score
50
40
30
20
Q1
Q5
Q5
Q5
Q5
Q5
Q6
Score
80
70
60
50
40
30
20
10
0
HR Ati
HD Oum Hadjer
HD Bitkine
Score
Q5
Informants in interviews and group
discussions highlighted a series of
changes in the way things are done at
facility level. One of these changes
was reflected by improvements in staff
motivation accompanied by increased
attendance and punctuality of health staff.
Several reports confirmed this.
“During strikes we did not close
the doors, instead we took the
opportunity” (FGD, member of a
heath centre management committee).
HD Melfi
“Since the project was implemented
there has not been one resignation,
which was not the case before; instead
we tend to reinforce staff by hiring
locally” (KII, district hospital
manager).
Figure 7. Evolution of quality scores in the south district hospitals
Q6
100
90
80
70
60
50
40
30
20
10
0
“Before PBF implementation we
were only two in the health centre;
now we have hired a nurse and two
community health workers; we are
now five and work with renewed
commitment” (KII, head of PHC).
HR Koumra
40
During the key informant interviews
and the focus group discussions, several
changes that occurred in the behaviour
of providers and the functioning of the
system emerged, as observed and attested
by key stakeholders. Some of these
changes are summarized below, focusing
on those that relate with the initial theory
of change underlying the PBF scheme.
“Since the introduction of PBF staff
enjoy working and are no longer
absent as was the case before; with
PBF you work a lot but you win a lot
too; we are encouraged by the money
we earn compared to our efforts and
our results” (KII, health worker in
PHC).
Figure 6. Evolution of quality scores in north district hospitals
Q4
Qualitative results
Improvements in ways of
“doing things” at facility level
70
Q4
were considered individually. Quality of
care in district hospitals also improved
with each evaluation and while crude
figures were better in the south, progress
made was more important in the north
(figures 6 and 7).
HPB Koumra
HD Moissala
HD Dono Manga
HD Lai
Secondly, as encouraged during the PBF
training and “coaching”, entrepreneurial
initiatives by health staff also sprang up,
boosted by the greater autonomy health
facilities enjoyed in using their funds.
These included incentives to patients who
accessed facilities (gifts to mothers such as
loincloths, baby clothes, soap, tea, sweets
for children), reduction in or exemptions
from user fees for some services, financial
motivation for traditional birth attendants
who encouraged mothers to deliver in
health centres.
With funds received from the PBF
scheme some PHCs also improved
working conditions for staff, as well
as hospitality and confidentiality for
patients. For example, some built delivery
rooms, buildings for immunization and
prenatal visits, or shelters for pregnant
women awaiting consultations. Some
also purchased curtains to increase
patients’ privacy, as well as other medical
equipment for consultations, delivery
tables, sterilizers, surgical devices etc. to
improve services. Many health facilities’
premises were repainted, gardens were
landscaped and grounds were kept clean.
“Though there is still some ways
to go in terms of mindset, things
have improved a lot in the area of
hygiene in general. Cleanliness is
ensured everywhere, making patients
wonder why there is such cleanliness
in structures which, only yesterday,
were filled with flies and other insects”
(KII, a member of a DHMT).
Improvements in health
facilities management
Prior to the implementation of the PBF
scheme, most PHCs did not have action
or business plans and this could impede
good governance. Those involved in
the project were required to have such
a document, which enabled a basic of
consensus on the activities to be carried
out. It was a requirement for contract
with the PPA.
“Now expenditures are made
according to the business plan and
the signed contract, after a meeting of
health-care providers and health centre
committee” (KII, head of a PHC).
PBF also greatly improved the presence,
as well as the filling in and archiving of
local health information tools, such as
facility registers for activities and funds.
Some registers, which had not been used
for many years, began being used again.
“Prior to PBF some registers such
as those related to patient referrals
or minor surgery did not exist;
this is not the case now, thanks
to recommendations made during
verifications” (KII, the superintendent
of a district hospital).
In fact, this register existed since
1988 according to a Chad health
system expert, but its use had been
discontinued.
Moreover, monthly financial reports of
PHCs were usually poor or not filled in
at all before PBF. As the scheme required
to have and use such registers (quality
checklist), PBF contributed, in some part,
to correcting this situation. Management
of drugs, their availability and storage also
improved in many health facilities.
“Prior to PBF we stored drugs in
cartons, but with money earned we
purchased medicine cabinets. In
addition, PBF funds enabled us to
purchase enough drugs, so shortages
are now rare” (FGD, manager of a
pharmaceutical depot).
Improvements in health
system regulation
Performance contracts were signed with
regulators at intermediate and peripheral
levels (i.e. regional services and DHMTs).
These contracts were assessed, and
regions/DHMTs paid, by using checklists
targeting their routine duties, such as
planning and monitoring of activities,
health facility supervision, effective analysis
of health information, completeness
and promptness in data transmission,
regular holding of statutory meetings etc.
Evaluations were made quarterly by the
purchasing agency. Such evaluations found
that substantial efforts in improvement
were made also at this level. Initially, most
of these activities were rarely, if at all,
carried out, while that was no longer the
case after introduction of PBF.
Discussion
Our results must be interpreted carefully.
One of the limitations of our data
and analyses is that they are based on
trends during the implementation of
the project only, as data relating to the
same indicators before the project are
not available. Thus a before and after
analysis is not possible. Moreover, we
have to bear in mind that this study is
not an impact evaluation with control
and intervention groups, and therefore
it is not possible to tease out the impact
of other factors, such as concurrent
activities of NGOs intervening in the
targeted health districts. The project
period was also too short to capture
all relevant effects or to ascertain
longer term trends and lasting changes.
Furthermore, the reliability of target
population data when assessing coverage
rates for services utilization is also a
limitation of the study, especially in the
northern regions (Batha and Guera).
Let us add that regarding quality of
care, checklists used to assess it had
limitations because they mainly focused
on structural indicators, with less
emphasis on processes and outcomes
ones. Finally, it is worth mentioning that
baseline studies had not been conducted,
so thorough comparisons with indicators
prior to the project’s start are not
possible. However, we believe that more
than their value, it is the evolution of the
indicators that matters. The limitations
of our data analysis remain substantial,
but these elements do not detract from
the relevance of our study and its
contribution to the main objective of
presenting data that often go unused,
and drawing preliminary lessons from
this pilot scheme.
Our findings show relatively positive
evolution in indicators of access and
quality of health services. These positive
results resonate with the findings of
our qualitative interviews. Indeed, the
qualitative investigation provides some
help in explaining the trends in the
indicators. They also confirm elements
of the PBF theory of change which is
built partly on the neoclassical theory
of “Homo economicus” maximizing its
utility.6 These important changes could
41
also be linked to the large growth margins
of most health indicators which were
originally very low in Chad (increasing
marginal returns). Indeed, in many health
facilities, consultations were extremely
low because patients were dissatisfied; so
there was room for greater workloads,
especially when there was a financial
motivation. Peaks observed between
July and October for “new cases of
curative consultations for under five”
were consistent with the rainy season, and
its set of endemic and epidemic diseases
(malaria, gastroenteritis, acute respiratory
infections etc.), while those observed
between January and April for “third
antenatal visit” correlated with the end
of farm activities, meaning women were
much freer to come to health facilities.
However, what is most interesting to
note are the vast performance disparities
between regions (and sometimes between
health centres in the same district even if
we didn’t show disaggregated data).
The first issue (disparities between
regions) highlights an initial important
lesson of our study, which is that
context matters a great deal. The
same intervention implemented in two
different contexts (geographic, climatic,
socioeconomic and cultural etc.) will
not have the same consequences with
regard to health outcomes. Secondly,
disparities between PHCs located in the
same district could be mostly explained,
based on our direct observations, by
differences in staffing, in health workers’
qualification and in lack of leadership
from managers. Indeed, generally, PBF
in Chad worked better in faith-based
facilities and where heads were actually
qualified and demonstrated strong
leadership.
Our results also highlighted the pilot’s
effect on better governance and
management of health institutions. But
despite these positive signs, more effort is
needed to make decision making happen
on a more empirical and rational basis.
We noted that in a large number of health
facilities, development of business plans
was neither rigorous nor actually effective,
owing to weak management capacity,
42
overall lack of human resources and low
levels of community participation. But
in health facilities with some potential
in relation to these elements, PBF easily
revived local initiatives even though
there is still a long way to go to establish
effective autonomy. Overall, management
of the local health information systems
also improved even though registers were
not always tailored to both health facility
and community verification requirements.
Thus, more appropriate tools need to
be devised, under the national health
information system, in order to facilitate
these verification activities while avoiding
duplication. Another issue that requires
close attention is better linking of
PBF with other financing mechanisms,
especially fee exemptions for emergency
care in hospitals (decreed since 2007 and
ongoing at the time of the study). A
decision (that was not yet effective) had
also been made to extend comprehensive
free care to all pregnant women and
children under five. The implementation
of these policies consists only in the
provision of drugs to health facilities,
without any effort to take into account
real needs in drug supply and changes at
other levels (increased workload, loss of
revenues for staff etc.), which obviously
raises major management challenges.
Some of the difficulties highlighted in this
article are structural and require systemwide actions. However, it seems clear
from our study that the introduction of
the PBF scheme in health facilities, even if
at pilot stage and poorly regulated, creates
almost instantly a positive momentum
as well as enthusiasm and buy-in from
most local players, highlighted by our
qualitative results. It is precisely this that
makes PBF so innovative.
Conclusion
As currently occurring in numerous subSaharan African countries, a PBF scheme
for health facilities was introduced in
Chad as a pilot project. Our analysis,
based on data collected through the PBF
system, as well as interviews and focus
group discussions, show that the PBF
scheme began to bear fruit after only 18
months of implementation. It induced
some strengthening of the health system
and good practices quickly took root.
Moreover, early results show improving
trends for some of the indicators observed.
However, results remain disparate across
regions and districts and between health
facilities. This confirms that PBF does
not operate mechanically and similarly in
all contexts, but rather acts as a catalyst to
address issues when some key conditions
are met. Our study presents some
limitations, but the changes highlighted
stress, more than ever, the need for
rigorous impact evaluations and for open
and evidence-based discussion in order
to tailor the design of PBF schemes to
specific contexts and policy needs, and to
better inform policy-making decisions on
PBF schemes, both at pilot stage and when
considering their rollout countrywide. p
Acknowledgements
Feedback was provided by Allison Gamble Kelley (health
economist) and Maria Paola Bertone (health policy, planning
and financing specialist). We thank key informants for
their participation, especially the head of the Direction
de l’Organisation des Services de Santé (DOSS) (Dr Dadjim
BLAGUE) and his staff, who were in charge of PBF at the MoH,
as well as the four health region managers. We also thank
Agence Européenne pour le Développement et la Santé
(AEDES) and Centre de Support en Santé Internationale
(CSSI) for their technical and logistical support. Funding was
received from the World Bank, through Projet Population et
Lutte contre le SIDA phase 2 (PPLS2). We thank its coordinator
(Mahamat Saleh) and his staff for their multifaceted support
References
1. Meessen B et al. Performance-based financing: just a
donor fad or a catalyst towards comprehensive healthcare reform? Bull World Health Organ 2011; 89:153–156.
2. Le Projet AIDSTAR-Two. Le manuel Financement basé sur la
performance : Conception et mise en oeuvre de programmes
efficaces de financement basés sur la performance (version
1.0). Cambridge, MA: Cambridge Management Sciences
for Health 2011.
3. MICS (Multiple Indicator Cluster Survey) Enquête par
grappes à indicateurs multiples Tchad 2010. Rapport final.
Ministère du Plan, de l’Economie et de la Coopération
Internationale du Tchad, INSEED, UNFPA, UNICEF; mai
2011.
4. WHO, UNICEF, UNFPA, World Bank. Trends in Maternal
Mortality: 1990 to 2010. WHO, UNICEF, UNFPA and World
Bank estimates. Geneva: World Health Organization 2012.
5. Ministère du Plan, de l’Economie et de la Coopération
Internationale du Tchad, Ministère de la Santé Publique du
Tchad, Banque Mondiale, Consortium AEDES/CSSI. Manuel
de procédures pour la mise en œuvre du financement basé
sur les résultats au Tchad. Août 2011.
6. Savedoff WD. Basic Economics of Results-Based Financing in
Health. Bath, Maine, USA: Social Insight 2010.
8
Estimating willingness to
pay for maternal health
services: The Kenya
reproductive health
voucher programme
Lucy Kanya,i Francis Obare,ii Benjamin Bellows,ii Brian Mdawida,ii
Charlotte Warren,iii Ian Askewii
Corresponding author: Lucy Kanya, e-mail: [email protected]
I
SUMMARY—As part of a broad evaluation of a
reproductive health voucher programme aimed
at determining its effect on health outcomes, a
willingness to pay (WTP) study was conducted. The
purpose of the study was to estimate WTP values
for a broad range of reproductive health (RH)
services namely: antenatal care (ANC), delivery,
postnatal care (PNC) and family planning (FP)
services. The study also sought to investigate the
effect of the voucher programme on respondents’
stated WTP values for the RH services. Women
utilizing RH services at both voucher and nonvoucher facilities were asked about their WTP
for the RH services and WTP values were elicited
using a stated preferences method. The study
found that women were willing to pay a positive
price to access RH services. Results also point
to a differential learning effect or experience
of the voucher on WTP for ANC, PNC, FP and
delivery services. Further analysis also highlights
endowment and reference effects with the
voucher cost impacting on stated WTP amounts.
The findings point to the potential for designing
a sliding scale payment mechanism with effective
targeting of subsidies such as vouchers to the
neediest segments of the population. This will
allow potential service users to pay for services
within their willingness and ability to pay while
also freeing resources to cater for the neediest
segments of the population.
nvesting in health is fundamental
to any poverty reduction strategy
as healthy individuals are key to the
economic productivity of any country.
Both high and low-income countries
finance health care using a mixture
of five possible sources: taxes, social
insurance contributions, private insurance
premiums, community financing and
direct out-of-pocket payments through,
for instance, user fees and patients’ direct
payment to private providers. 1 Faced
with serious economic challenges, many
governments in developing countries
introduced user fees for health care as
part of a sector-wide approach to cost
recovery and revenue generation. 1,2
However, available evidence suggests
that some service price levels discourage
health service utilization by the poor and
drive individuals into poverty.3–6
Increasingly, governments in low-income
countries and other purchasers of healthcare services are experimenting with
combinations of demand and supply
side financing mechanisms such as the
use of output-based aid (OBA) voucher
subsidies. While supply-side investments
aim at supporting the health system
issues through initiatives such as capital
investments, demand side financing
structures target the health system user,
driving them to utilize health facility
based services. Such mechanisms include
health voucher programmes which place
purchasing power directly in the hands of
potential health-care users, giving them
choice of health-care service providers
and services. The strategies, mostly
targeting the poor, have been used to
improve uptake of health-care services in
developing countries.7–12 While vouchers
i Brunel University London, United Kingdom
ii Population Council, Nairobi, Kenya
iiiPopulation Council, Washington, DC, United States of America
43
are not issued free of charge, the cost is
minimal with substantial benefits to the
voucher holder, thus heavily subsidizing
the cost of health care. However, there
have been concerns about the potential
impact of subsidies such as vouchers
on adoption of pricing mechanisms
when the subsidy is withdrawn.7,13–16 The
concerns arise from the fact that in health,
like many other fields, decision makers
are often faced with the challenge of
balancing the need for equitable access
to services especially for vulnerable lowincome populations and the desire to
avoid setting prices that are too low to
sustain programmes, which could lead to
over-reliance on external funding.17 It is
therefore imperative to price health-care
services and products and charge those
that can afford to pay a partial or full cost,
which is then used to subsidize the cost
of care for those who cannot afford to
pay for them.
Setting optimal pricing levels for
health-care services can be informed
by individuals’ monetary valuation
of the benefits derived from the
interventions. 18–20 However, health
interventions are not subject to the normal
economic market for goods and services,
making it difficult to value benefits that
can be derived from them. Among the
methodologies used to elicit individuals’
monetary valuations of programme
benefits include WTP studies.21–24 The
theoretical foundations of WTP as a
measure of commodity and service value
are rooted in consumer demand theory.25
Individual WTP values point to consumer
choice behaviour or preferences with
regard to particular goods or services.25
WTP studies in the health sector build
on the quality adjusted life year (QALY)
measurement to elicit a dollar value from
people for a good that is not subject to
market pricing mechanisms.26,27 Individual
preferences are weighted on money,
health and time, with immediate and
higher impact interventions expected to
be valued higher than interventions where
the outcome is expected at a future date
or deemed to have a lower impact.
A number of possible scenarios have
been identified in the literature regarding
the possible influence of health-care
subsidies on individuals’ monetary
valuation of benefits. For instance,
44
where the service has been obtained,
beneficiaries are likely to be more willing
to pay for subsequent use because they
have experienced the true value of the
service – the learning effect.13 Subsidy
beneficiaries may also anchor around the
subsidy price and would be unwilling to
pay more for the intervention later.13 The
price of the subsidy in this case acts as the
reference point on which the stated WTP
preferences are conditioned.14–16,28 In other
cases, subsidies create an endowment
effect whereby individuals’ stated WTP
preferences are based on their experiences
with the subsidized service or intervention
(whether positive or negative). In the
case of positive experiences, the stated
WTP value is expected to be higher
while for negative experiences, the stated
WTP value is expected to be lower.29
In the case of cost-free subsidies (such
as childhood immunizations in many
settings), beneficiaries easily develop an
entitlement effect and are unwilling to pay
any amount for the intervention later.14
Although output-based aid voucher
programmes are increasingly being
implemented in developing countries
to improve the uptake of health-care
services especially among economically
disadvantaged populations, there is limited
understanding of how and the extent
to which they influence beneficiaries’
monetary valuation of the subsidized
services when the voucher is withdrawn.
This article examines individuals’ WTP
for RH services in Kenya. It specifically
compares the likelihood that individuals
were willing to pay and the amount they
would be willing to pay for ANC, delivery,
PNC and FP services among voucher
and non-voucher clients. Information
on WTP values for health-care services
is useful for predicting utilization or
demand for an intervention, services or
commodities.18,19,30 When obtained before
the rollout of a health intervention, an
analysis of WTP values can also be used
to determine the need for a subsidy.6,18,19,31
In particular, if the stated WTP is less
than the real cost of the intervention,
then a subsidy would be needed to ensure
equitable access to the services while
higher stated WTP values may indicate
the ability of the specific population
group to pay for the services and may be
used in pricing level decisions.
Maternal health indicators in
Kenya
Although the year set for achieving the
Millennium Development Goal (MDG)
targets32 is upon us, Kenya is far from
attaining its indicators on maternal and
child health. According to the Kenya
Demographic and Health Sur vey
(KDHS), maternal mortality increased
from 414 in 2003 to 488 in 2008–09.
Despite several interventions to improve
health outcomes, skilled birth attendance
(SBA) – which is recognized as a key
strategy in addressing maternal mortality
– is still low at 44%. Moreover, although
92% of expectant women receive
ANC from a health-care provider, only
44% of births are delivered in a health
facility. Only 47% of mothers seek PNC
care services while the contraceptive
prevalence rate is 46%.33 Factors that
contribute to the low uptake of the
health-care services in Kenya and similar
settings include poverty, availability and
spread of health facilities, low literacy,
shortage of staff and supplies, healthcare provider attitudes and sociocultural
practices.33–38 Uptake of RH services
remains low especially among individuals
from poor households.33
Health-care financing in
Kenya
Different policy instruments have been
utilized by successive governments to
finance health care in the country. From a
predominantly tax-funded system in 1963,
a variety of cost recovery mechanisms
including full cost (user fees) and
registration fees have been used together
with exemption mechanisms to cushion
vulnerable segments of the population
from finance-related barriers to accessing
health care. There is a national health
insurance scheme that initially targeted
the formal sector but successively
opened up to include the informal sector.
There are also private health insurance
schemes while the government recently
commissioned a social health insurance
scheme. Under Article 43(1) (a) of the
Constitution of Kenya, every person
has the right to the highest attainable
standard of health, which includes the
right to health-care services, including
RH care.39 The full realization of this
right has, however, been hampered by
stunted economic growth coupled with
competing financial needs against a fixed
budget.
As a signatory to the Abuja Declaration,
Kenya committed itself to allocating
at least 15% of the national budget to
the health sector.40 However, more than
a decade after signing the declaration,
government funding for health care has
remained consistently below 5%.41 In
2009–10, the government contributed
30% of the health budget, households
and other private sources contributed
54%, while donors contributed 16%.
However, the total health expenditure
for RH accounted for 14% of total health
spending and 1% of GDP in 2009–10, a
level that has remained unchanged since
2005–2006.42 Public and private sectors
(including households) were the primary
sources of RH care financing during the
period of analysis with contributions of
40% and 38% respectively.42 Household
financing of health care is largely through
formal and informal out-of-pocket
payments, which have been linked to poor
uptake of facility services, hence poor
maternal health outcomes. It is against
this backdrop that the Government of
Kenya began implementing the RH
vouchers programme (described in
detail in the next section) in selected
regions of the country. The government
further declared a policy of free maternal
health services (ANC, delivery and PNC
services) in all public health facilities in
2013.43 Following the policy shift, public
health facilities have reported influxes in
the numbers of maternal delivery.44
The reproductive health
vouchers programme in
Kenya
Through funding from the German
Develo p men t Bank (KfW), an
output-based aid (OBA) RH voucher
programme has been implemented by
the Government of Kenya since 2006.
The OBA concept represents a demandside approach to financing health care
by subsidizing health-care clients directly
and dispensing money to health facilities
only when services are actually provided.
The programme, described in detail
elsewhere12,45–47 is implemented in select
sites within three districts (now counties):
(Kisumu, Kitui and Kiambu) and two
urban slums (Viwandani and Korogocho)
in Nairobi since 2006. The programme
was expanded to one additional county
(Kilifi) in 2011. The objective of the
programme is to significantly reduce
maternal and neonatal morbidity and
mortality by increasing the number of
health facility deliveries and improving
access to appropriate RH services
for the poor through incentives for
increased demand and improved service
provision.8,48,49
Using a non-standard poverty-grading
tool, community-based distributors
appointed by the voucher management
agency screen self-selecting pregnant
women and potential FP clients, who, if
eligible, purchase a safe motherhood or
FP voucher respectively at a minimal fee
or are given for free if living in extreme
poverty. The safe motherhood voucher
costs KSh 200 (US$ 2.50) and covers four
ANC visits, normal or surgical delivery,
pregnancy complications and PNC for
the mother and baby up to six weeks.
The FP voucher costs KSh 100 (US$1.25)
and covers long-term and permanent
methods (contraceptive implants,
intrauterine contraceptive device and
voluntary tubal ligation). A third voucher
for gender-based violence recovery
(GBVR) services is issued for free at
selected health facilities to gender-based
violence (GBV) survivors. The voucher
covers consultation, counselling services,
laboratory examinations and treatment of
conditions arising from GBV.
Beneficiaries present the vouchers for
services at the more than 150 accredited
health (voucher) facilities comprising
public, private for-profit and private notfor-profit. Following service provision,
facilities submit invoices to the voucher
management agency for payment against
pre-agreed reimbursement rates. The RH
voucher programme has been evaluated
on several facets including its impact on
access to services,50 impact on quality
of care51 and the economic costs of
providing the different RH programme
services (unpublished work).
Evaluation of the programme has shown
improved service utilization among the
target population.49,11,50
Methods
Data
Data for this analysis and paper was
collected during exit interviews with
clients seeking ANC, PNC and FP
services in selected health facilities in
Kenya. The study was conducted between
July and October 2012 as part of a larger
project that evaluated the impact of
reproductive vouchers programmes in
five countries (Kenya, Uganda, United
Republic of Tanzania, Cambodia and
Bangladesh).
A total of 33 health facilities were
randomly sampled from among those
that were accredited to provide services to
voucher beneficiaries. The sampling was
stratified by programme site (Kisumu,
Kitui, Kiambu, Kilifi and Nairobi), facility
level (hospital, health centre/maternity/
nursing home and dispensary/clinic)
and facility type of ownership (public,
private, faith-based and NGO). A further
18 health facilities were sampled from
adjacent non-voucher sites (Makueni,
Nyandarua and Uasin Gishu counties)
for comparison. Health facilities in the
comparison sites were selected on the
basis of how comparable they were to
those sampled from voucher sites in terms
of level and type of ownership. In the
absence of pre-implementation data, the
study authors chose to compare voucher
and non-voucher clients in an effort
to separate the effect of the voucher
programme on stated WTP values.
The study targeted expectant women
making the first (under 24 weeks) and
last (36 weeks or more) ANC visit;
postpartum women seeking PNC services
within 48 hours, two weeks, and four
to six weeks after delivery; and women
seeking FP services. As part of the larger
programme evaluation, the women were
first observed during consultation with
the providers to determine the quality of
care they received. The observations were
conducted by trained nurses who were
deployed outside the study area. Quality
of care assessments were conducted
using a different tool to the one used to
capture stated WTP values. The detailed
methodology and results of the quality of
care assessments are not presented in this
article but covered in detail in a separate
focused paper.51
45
WTP data were captured using a
structured questionnaire administered
during exit interviews. Following the
observations described above, clients
were interviewed after consultation
sessions by trained research assistants.
The structured questionnaires used during
the exit interviews captured information
on the clients’ background characteristics
(including age, education level, marital
status and household income);
childbearing experiences and intentions;
perceptions about the services received;
accessibility to the facility (mode and time
of travel); out-of-pocket expenditure and
WTP for the services including a stated
WTP value for the different RH services;
as well as awareness, use and perceptions
about the vouchers. PNC clients were
also asked about their experiences during
delivery.
Written informed consent was obtained
from all participants before conducting
the observations and interviews. The
interviews were conducted in English,
Swahili (the national language) or the
local language depending on which one a
participant was comfortable with. Ethical
approval for the study was obtained from
the Population Council Institutional
Review Board (Protocol No. 470) and
the Kenya Medical Research Institute
(Protocol No. 174).
Analysis
46
the amount of money clients were willing
to pay for services respectively. A total of
eight models were estimated. The first
four models examined differences in the
likelihood of WTP for the services (ANC,
delivery, PNC and FP) among voucher
and non-voucher clients. The results are
presented as odds ratios. The next set
of four models examined differences in
the amount voucher and non-voucher
clients were willing to pay for the services.
The results are presented as coefficient
estimates. The models adjusted for
clustering of individuals within the same
facility. The basic form of the model is
given by the following equation:
Yij = 0 + i Xij+ j
where Yij is the amount paid by individual
i in facility j, 0 is the constant, Xij is
the vector of covariates including the
indicator of whether one was a voucher
client or not, i is the associated vector
of fixed parameters and j is the error
term for individuals identified from the
same facility. The models controlled
for age, highest education level, marital
status at the time of interview, parity,
household wealth index, type and level of
facility. The definitions and measurement
of variables included in the regression
models are presented in Table 1.
Interviews were completed with 419 out
of 432 ANC clients (97%), 554 out of
568 PNC clients (98%) and 212 out of
216 FP clients (98%).
Characteristics of women
Table 2 presents the distribution of ANC,
PNC and FP clients that were successfully
interviewed upon exit by background
characteristics and use of voucher. There
were no significant variations in the
distribution of voucher and non-voucher
clients seeking various services (ANC,
PNC and FP) by age and marital status.
However, voucher and non-voucher
clients seeking ANC and PNC services
significantly differed in terms of highest
level of education, household wealth
status, and the facility from where they
were interviewed. In particular the highest
proportion of voucher clients seeking
ANC and PNC services had primary level
education (57% and 68% respectively).
By contrast, the highest proportion
of non-voucher clients seeking these
services had secondary and above level
of education (57% and 52% respectively).
Similarly, higher proportions of nonvoucher compared to voucher clients
Table 1. Definitions and measurement of variables included in regression
analysis
Analysis involved descriptive statistics
(means and percentages) as well as
estimation of multivariate regression
models. We compared the proportions
of voucher and non-voucher clients who
indicated that they were willing to pay for
ANC, delivery, PNC and FP services and
tested whether there were any significant
differences between the two groups. We
further compared the average amount of
money that voucher and non-voucher
clients were willing to pay for the services
and tested whether differences, if any,
were statistically significant. Voucher
clients in this case referred to those who
had ever used FP or safe motherhood
vouchers even if they did not use it on
the day of the interview.
Variable definition
Multivariate regression analysis, on the
other hand, involved estimation of logistic
and ordinary least squares regression
models for the likelihood of WTP and
Results
Measurement
Outcome variables
Willing to pay for services (ANC, delivery, PNC, FP)
0 = No
1 = Yes
Amounts clients are willing to pay
Continuous:
Ranges from KSh 10 to KSh 2000 for ANC
Ranges from KSh 20 to KSh 25000 for delivery care
Ranges from KSh 10 to KSh 8000 for PNC
Ranges from KSh 20 to KSh 1000 for FP
Covariates
Client type
0 = Non-voucher client
1 = Voucher client
Current age of the respondent
Continuous:
Ranges from 15 to 44 for ANC clients
Ranges from 15 to 49 for delivery and PNC clients
Ranges from 17 to 49 for FP clients
Education level
0 = No schooling/pre-unit/primary
1 = Secondary and above
Current marital status
0 = Never/formerly married
1 = Married/living together
Household wealth index
0 = Other 60%
1 = Poorest 40%
Parity
Continuous:
Ranges from 1 to 5 for ANC clients
Ranges from 1 to 7 for delivery, PNC and FP clients
Facility type
0 = Private
1 = Public
Facility level
1 = Hospital
2 = Health centre/maternity/nursing home
3 = Dispensary/clinic
Kenya shilling (KSh): US$ 1 ≈ KSh 88
seeking the services were from the two
bottom quintiles. In addition, although
the majority of clients were from public
health facilities, a higher proportion of
non-voucher compared to voucher clients
was from these facilities.
Willingness to pay for
services
Table 3 shows the distribution of
voucher and non-voucher clients by
WTP for RH services. There was no
significant difference in the proportion
of voucher and non-voucher clients that
were willing to pay for ANC services
(35% and 33% respectively; p=0.67).
However, a significantly lower proportion
of voucher compared with non-voucher
clients were willing to pay for delivery
(34% and 43% respectively; p<0.05) and
FP services (25% and 44% respectively;
p<0.05). By contrast, a significantly
higher proportion of voucher compared
with non-voucher clients were willing
to pay for PNC services (47% and 39%
respectively; p<0.05). The results further
show that voucher clients were willing
to pay significantly lower amounts for
ANC (p<0.05), delivery (p<0.01) and
PNC services (p<0.01) compared with
non-voucher clients (Table 3). It is also
worth noting that, on average, voucher
clients were willing to pay lower amounts
than the voucher price for ANC and FP
services. By contrast, they were willing to
pay almost three times higher for delivery
than the voucher price and almost the
same price for PNC as the voucher price
(Table 3).
Results from the multivariate logistic
regression analysis show that voucher
clients were significantly less likely to
express WTP for ANC, delivery and FP
services compared with non-voucher
clients (p<0.05 in each case; Table 4).
There was, however, no significant
difference between voucher and nonvoucher clients in the likelihood of
expressing WTP for PNC services.
Other results from the analysis show
that clients with secondary and above
level of education were significantly more
likely to report WTP for delivery services
compared with those with lower levels
of education (odds ratio: 1.65; p<0.01).
In addition, contrary to what would be
expected, women from the poorest 40%
of households and those who sought
services from dispensaries or clinics
were significantly more likely to report
WTP for ANC services compared with
those from the other 60% households
and those who sought services from
hospitals respectively (p<0.05 in each
Table 2. Percentage distribution of voucher and non-voucher clients by background characteristics and services sought
Antenatal care (%)
Characteristics
Age (years)
Voucher clients
Non-voucher
clients
p=0.30
Delivery/postnatal care (%)
Voucher clients
Non-voucher
clients
p=0.25
Family planning (%)
Voucher clients
Non-voucher
clients
p=0.93
15–24
50.0
47.9
52.4
44.7
39.6
37.1
25–34
40.1
45.0
35.6
38.9
47.2
47.8
35 and above
8.8
7.1
10.3
14.5
13.2
14.5
Don’t know/missing
1.1
0.0
1.7
1.9
0.0
0.6
Highest education level
p<0.01
p<0.01
p<0.05
No schooling/pre-unit
6.6
2.9
7.9
2.3
9.4
3.1
Primary
57.1
39.9
67.8
46.2
66.0
58.5
Secondary and above
36.3
57.1
24.3
51.5
24.5
38.4
Current marital status
p=0.78
p=0.62
p=0.87
Never married
15.4
13.9
11.6
13.4
11.3
9.4
Married/living together
80.8
83.2
86.0
83.2
84.9
85.5
3.9
2.9
2.4
3.4
3.8
5.0
Formerly married
Parity
p=0.16
p=0.01
p=0.54
0
37.4
41.6
0.3
3.4
0.0
3.1
1–2
38.5
42.9
52.1
63.4
54.7
57.9
3–4
19.2
11.8
33.6
24.4
32.1
27.0
5 and above
5.0
3.8
14.0
8.8
13.2
12.0
Household wealth index
p<0.01
p<0.01
p<0.32
Poorest quintile
11.0
34.5
8.2
30.5
9.4
17.6
Poorer quintile
19.8
20.2
21.2
19.1
17.0
22.0
Middle quintile
26.4
11.8
25.7
19.9
26.4
17.6
Richer quintile
19.8
18.1
25.7
16.0
18.9
21.4
23.1
15.6
19.2
14.5
28.3
21.4
Richest quintile
Facility type
p<0.01
p<0.01
p<0.01
Private
37.9
19.8
40.4
19.1
41.5
13.8
Public
62.1
80.3
59.6
80.2
58.5
86.2
Facility level
p=0.08
p<0.01
p<0.01
Hospital
50.6
60.1
55.5
66.4
20.8
52.8
Health centre/maternity/nursing home
46.2
38.7
39.7
32.4
67.9
46.5
Dispensary/clinic
3.3
1.3
4.8
1.2
11.3
0.6
Number of women
182
238
292
262
53
159
Percentages may not total 100 due to rounding; p values are from chi-square tests of differences between voucher and non-voucher clients
47
Table 3. Distribution of voucher and non-voucher clients by willingness to pay
for reproductive health services
Voucher clients
Indicator
Non-voucher clients
Estimate
Number of cases
Estimate
Number of cases
35.2
33.6
47.3
24.5
182
292
292
53
33.2
42.8*
38.6*
44.0*
238
262
262
159
67.53
706.40
198.80
34.23
170
267
275
52
130.14*
1776.63**
474.98**
42.89
138
169
191
152
0.0
0.0
10.0
0.0
170
267
275
52
40.0
500.0
20.0
0.0
138
169
191
152
Proportions willing to pay for services (%)
Antenatal care
Delivery care
Postnatal care
Family planning
Mean amount clients are willing to pay (KSh)
Antenatal care
Delivery care
Postnatal care
Family planning
Median amount clients are willing to pay (KSh)
Antenatal care
Delivery care
Postnatal care
Family planning
Kenya shilling (KSh): US$ 1 ≈ KSh 88; Differences between voucher and non-voucher clients are statistically significant at:
*p<0.05; **p<0.01. Number of cases = number of individuals responding to the question. Estimates for proportions willing to pay
for services = percentage based on the total number of respondents for the question. Estimates for the WTP values = absolute
values in KSh.
case). By contrast, women who sought
services from health centres, nursing or
maternity homes were significantly less
likely to express WTP for ANC services
compared with those who sought services
from hospitals (p<0.05; Table 4).
Table 5 presents coefficient estimates from
ordinary least squares regression analysis
for amounts that clients were willing to
pay for various RH services. Voucher
clients were willing to pay significantly
lower amounts for delivery and PNC
services compared to non-voucher
clients (p<0.01 in each case). There
was, however, no significant difference
between voucher and non-voucher clients
in the amounts they were willing to pay
for ANC and FP services. Other results
show that women with secondary and
above level of education were willing
to pay significantly higher amounts for
ANC compared with those with lower
levels of education (p<0.05). In addition,
women who sought services from public
health facilities and dispensaries/clinics
were willing to pay significantly lower
amounts for PNC compared with those
who sought services from private facilities
and hospitals respectively (p<0.05 and
p<0.01 respectively).
Discussion and
conclusion
This study explored WTP for RH services
among poor women within the context of
Table 4. Odds ratios from logistic regression models for the likelihood of willing to pay for reproductive health services
among voucher and non-voucher clients
Covariates
Voucher client (yes = 1)
Antenatal care
Delivery care
Postnatal care
Family planning
0.55* (0.31; 0.99)
0.32** (0.19; 0.54)
0.87 (0.42; 1.79)
0.36* (0.14; 0.94)
Age (single years)
0.96 (0.90; 1.03)
0.98 (0.92; 1.05)
0.95* (0.91; 0.99)
1.02 (0.97; 1.09)
Highest education level (secondary and above = 1)
1.51 (0.99; 2.29)
1.65** (1.16; 2.35)
1.35 (0.91; 2.01)
0.91 (0.50; 1.67)
Current marital status (married/living together = 1)
0.99 (0.49; 2.03)
0.82 (0.45; 1.47)
0.89 (0.51; 1.57)
1.09 (0.50; 2.36)
Parity (continuous)
1.19 (0.97; 1.47)
1.02 (0.83; 1.25)
1.19 (0.99; 1.42)
0.79 (0.62; 1.01)
Household wealth index (poorest 40% = 1)
1.67* (1.03; 2.67)
1.16 (0.98; 2.66)
1.57 (0.97; 2.52)
0.79 (0.38; 1.62)
Facility type (public = 1)
1.13 (0.53; 2.42)
0.72 (0.38; 1.39)
0.47 (0.21; 1.08)
0.62 (0.28; 1.37)
Facility level (ref = hospital)
Health centre/maternity
Dispensary/clinic
Number of cases
0.48* (0.24; 0.96)
0.87 (0.46; 1.67)
0.55 (0.26; 1.15)
0.92 (0.45; 1.89)
1.92* (1.01; 3.62)
0.64 (0.10; 4.26)
0.55 (0.10; 3.17)
0.57 (0.20; 1.60)
305
426
458
203
Ref: reference category; *p<0.05; **p<0.01
Table 5. Coefficient estimates from ordinary least squares regression models for the amount clients are willing to pay
for reproductive health services
Covariates
Voucher client (yes = 1)
Age (single years)
Delivery care
Postnatal care
Family planning
-814.26** (-1355.06; -273.45)
-290.20** (-486.21; -94.19)
-13.02 (-45.27; 19.24)
-4.47 (-10.37; 0.89)
93.73 (-11.55; 199.01)
-4.03 (-18.06; 10.00)
0.41 (-3.93; 4.76)
Highest education level (secondary and above = 1)
66.81* (13.48; 120.14)
241.54 (-364.00; 847.09)
224.16 (-8.08; 456.40)
0.56 (-25.95; 27.06)
-16.83 (-68.46; 34.79)
Current marital status (married/living together = 1)
-4.87 (-83.27; 73.52)
-642.79 (-1501.00; 215.42)
-11.67 (-224.99; 201.66)
Parity (continuous)
14.33 (-5.04; 33.70)
-280.33 (-671.86; 111.20)
25.37 (-22.98; 74.72)
-5.44 (-19.43; 8.56)
Household wealth index (poorest 40% = 1)
13.40 (-49.14; 75.94)
495.06 (-273.61; 1263.72)
-73.64 (-244.62; 97.34)
-19.22 (-42.59; 4.14)
Facility type (public = 1)
-33.03 (-123.60; 57.55)
-582.69 (-1344.04; 178.65)
-248.38* (-492.34; -4.42)
-24.75 (-57.95; 8.46)
Facility level (ref = hospital)
Health centre/maternity
-64.28 (-130.95; 2.38)
45.44 (-640.76; 731.85)
-129.44 (-325.57; 66.70)
-8.26 (-39.78; 23.26)
-9.95 (-91.52; 71.61)
-570.85 (-1489.99; 348.30)
-213.97** (-362.89; -65.05)
-17.40 (-62.85; 28.05)
242.65* (43.38; 441.91)
588.90 (-1365.14; 2542.94)
719.70** (296.37; 1143.02)
92.55* (6.54; 178.56)
305
426
458
203
Dispensary/clinic
Constant
Number of cases
Ref: reference category; *p<0.05; **p<0.01
48
Antenatal care
-52.12 (-118.65; 14.40)
a voucher programme and comparable
non-voucher sites. In addition to
estimating average WTP values for the
RH services, this study explored the effect
of the subsidy (voucher/voucher price)
on WTP for similar services in future.
A key finding of this study was that
clients are willing to pay a positive price
for the four reproductive health services:
ANC, delivery, PNC and FP. This finding
mirrors findings in other studies on the
effect of vouchers on utilization of
facility based RH services in which the
voucher is associated with improvements
in quality of care and perceived benefit of
attending facility based services leading to
the increased utilization of facility based
services.12,48,50
A second finding from these results was
that experiencing the services – learning
effect of the voucher subsidy impacts
differently for the different RH services.
A negative effect of the voucher was
observed in the lower proportions of
voucher clients compared with nonvoucher clients, willing to pay for ANC,
delivery and FP services while the
voucher positively impacts on WTP for
PNC services with more voucher than
non-voucher clients expressing WTP for
the services in future. In the design of the
voucher programme before 2014, clients
were expected to access PNC services
using the safe motherhood voucher.
However, the facility reimbursement
policy for PNC services offered was not
clear as this was lumped into delivery
services and thus many facilities did not
consider PNC services after delivery
and discharge to be part of the voucher
benefits. It is possible therefore that
voucher clients paid to access PNC
services for services offered post
discharge. Anecdotal evidence collected
from voucher clients in the process of
the wider programme evaluation points
to poor attitudes towards voucher paying
clients at voucher facilities, compared
with regular fee-paying clients. These
clients intimated that at some of the
facilities, providers felt that the voucher
programme had led to an influx of clients
in their facilities increasing their workload
yet they were not compensated for the
extra workload. This was observed more
in the public facilities where facility
earnings from the voucher programme
did not directly impact financially on
the service providers. Some of the
service providers in such facilities gave
preferential treatment to the fee-paying
clients, with voucher clients attended to
after these had been served. Poor provider
attitudes to clients have been documented
in other studies as a leading cause of
non-utilization of health facilities.34 These
contributed to the clients’ decision to
conceal the voucher, using it only if they
were in an emergency situation.52 Such
experiences would lead to the low stated
WTP values for these services when
offered in the context of a voucher
programme. The low stated WTP values
could also be attributed to normalization
of services such as ANC and delivery in
majority of the communities within the
study area, as shown in other studies.34,38
In these, pregnancy is not associated with
any dangers and thus facility attendance
is reserved for emergencies. The learning
effect also influences the WTP amounts
with voucher clients willing to pay less for
ANC, delivery services and PNC services.
Data on the FP service clients are very
limited and the resulting analysis is not
sufficiently convincing.
A third major finding is the effect of
the current voucher price on the stated
WTP amounts for all the services – the
reference point effect. Overall, voucher
clients are less likely to express WTP for
ANC, delivery and FP services, compared
with non-voucher clients. This could also
be tied to the above finding on the effect
of previous experiences with services
offered using the voucher. With a cost
price of KSh 200 for the safe motherhood
voucher, voucher clients are willing to pay
lower than this price for ANC and FP
services but almost three times this price
for delivery services. Normalization of
ANC and FP services could contribute
to this. In this, delivery is associated with
higher health risks compared with ANC
and FP and thus higher WTP values are
stated for this. The voucher price does
not have an effect on WTP price for
PNC services.
The study findings concur with findings
in other studies where subsidies have been
shown to have a learning effect on stated
WTP for the services.13–15,18 The same
studies have also pointed to the potential
negative effect of the subsidy cost as
used as a reference point, on stated WTP
amounts. Findings from this and similar
studies can be used to set minimum
price levels for health commodities and
services, allowing those in the society
who can pay a non-zero price to access
health care to do so. Interventions aimed
at addressing disrespectful and abusive
care towards clients, which includes
discrimination on the basis of their
49
socioeconomic background, are ongoing
in the country.53 It is hoped that these
will reduce the perceived discrimination
of voucher clients on the basis of
ownership of the voucher, encouraging
equal treatment for equal need.
As has been the case with other
studies 18,19,54 findings from this WTP
study could help project the market size
for RH services if these were priced.
To generate further evidence for resource
allocation and pricing decisions, variations
of the different methods of eliciting
WTP values should be conducted on
the same sample as has been suggested
by Foreit17. This further helps to validate
the stated WTP values. In addition, an
in-depth evaluation of the reasons for
the stated WTP values and non-WTP for
services would aid in redesigning payment
mechanisms. p
Acknowledgements
The reproductive health voucher programme is implemented
by the Government of Kenya with major funding from the
German Development Bank (KfW). The evaluation project
was funded by the Bill & Melinda Gates Foundation and
implemented by the Population Council in collaboration
with the National Council for Population and Development
(NCPD), the Ministry of Health and PriceWaterhouseCoopers.
The project obtained ethical and research clearance from
the Institutional Review Board of the Population Council,
the Ethics Review Committee of the Kenya Medical Research
Institute (KEMRI), the National Council for Science and
Technology (NCST) and the Ministry of Health. The opinions
expressed in this paper are, however, solely those of the
authors and do not necessarily reflect the views of the funding
or implementing agencies.
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9
Fondements de la
résilience et de la
pérennité de la mutuelle
de santé Fandène,
Sénégal
Aboubakry Gollock,i Slim Haddad,ii Pierre Fournieriii
Auteur correspondant : Aboubakry Gollock, e-mail : [email protected]
L
RÉSUMÉ—La stratégie sénégalaise de la
couverture maladie universelle (CMU) vise,
entre autres, à porter le taux de pénétration
des mutuelles de santé (MS) à 65,5 % en
2017. L’objectif de cet article est d’analyser les
fondements de la résilience et de la pérennité de
la plus ancienne MS communautaire rurale du
Sénégal (MS de Fandène) et de tirer les leçons
de son expérience pour la CMU. Il repose sur une
étude de cas avec : recherches documentaires,
entrevues individuelles et focus groupes avec les
membres, ex-membres et responsables de la MS
entre 2012–2013, codage des données avec QDA
Miner et analyse thématique des contenus. La
résilience et pérennité de cette MS s’expliquent par
les conditions de sa création, les caractéristiques
de sa population cible, la réciprocité élargie, la
gouvernance, la confiance et la conscience critique
des membres ainsi que la qualité des soins. Elle a
favorisé la solidarité, l’accès aux soins de qualité et
acquis au fil des années une légitimité qui en fait
un partenaire crédible pour la CMU. Certaines de
ses faiblesses montrent les difficultés rencontrées
pour atteindre la CMU avec des adhésions
volontaires et des MS de petites échelles. À terme,
la CMU obligatoire et le financement public
seraient plus indiqués pour assurer une couverture
adéquate, équitable et pérenne des populations.
es mutuelles de santé (MS) sont des
régimes de prépaiement volontaire
à base communautaire qui offrent
une assurance contre les risques maladie
aux membres en contrepartie d’une
cotisation périodique. Leur principal
objectif est de limiter les effets pervers
des paiements directs de services de
santé sur les populations. Elles ciblent
principalement le secteur informel et le
monde rural. Au Sénégal, elles occupent
une place importante dans la stratégie
nationale de la couverture maladie
universelle (CMU) dont l’un des objectifs
est de faire passer le taux de couverture
de ces organisations de 13,6 % en 2012 à
65,5 % en 2017.1
Des études montrent cependant qu’elles
sont confrontées à des risques de pérennité
financière et organisationnelle. 2–5
L’ampleur des problèmes auxquels font
face ces organisations occulte souvent les
expériences qui peuvent être considérées
comme des succès relatifs.
Par ailleurs, la recherche sur les MS
se limite (trop) souvent aux aspects
techniques et financiers liés à leur
montage et néglige les facteurs humains
et relationnels qui pourraient contribuer
à façonner leur performance et attrait
auprès de leur population cible. Les
valeurs et préférences des utilisateurs
ainsi que l’environnement structurel et
socioculturel des MS sont peu étudiées.6
La confiance, la réciprocité, la solidarité
et l’entre-aide, la cohésion des groupes
cibles, les perceptions par rapport à
l’intégrité des acteurs et les expériences
antérieures ont été abordées mais souvent
sous l’angle de leur incidence sur la
décision des populations à s’enrôler ou
non dans les MS.6–13 Leurs effets sur la
résilience et pérennité des MS n’ont que
peu été investigués dans ces recherches.
En définitive, il existe peu de données
probantes qui nous permettent de
comprendre pourquoi certaines de ces
organisations sont très vulnérables aux
chocs alors que d’autres, bien que peu
nombreuses, sont à la fois résilientes
et pérennes. Et, dans quelle mesure
les aspects humains et relationnels qui
régissent la création et le développement
des MS influencent-ils les performances
respectives dans ces domaines ?
L’objectif de cette recherche est d’analyser
les fondements économiques, sociaux et
culturels de la résilience et de la pérennité
de la plus ancienne mutuelle de santé
communautaire rurale du Sénégal (la MS
de Fandène) et de tirer les leçons de son
expérience en termes de bonnes pratiques
pour l’extension de la CMU.
Pourquoi la MS de Fandène ?
La MS de Fandène a été créée en 1988
par les habitants du village du même
nom. C’est une initiative endogène ; elle
n’a bénéficié de l’appui d’aucun bailleur
de fonds étranger lors de sa création.
Sa population cible est composée
principalement d’agriculteurs et de
travailleurs du secteur informel. En 2012,
elle comptait 602 membres pour 3 925
bénéficiaires sur une population d’environ
5 000 habitants. Ce qui fait de ce village
l’une des zones où le taux de couverture
contre le risque maladie est le plus élevé
au Sénégal.
See page 71 for the summary in English.
i CR-CHUM (Axe santé mondialer), Université de Montréal
ii CR-CHUM, Université de Montréal
iiiEPSUM, Université de Montréal
51
Depuis sa création, elle a été confrontée
à plusieurs chocs endogène et exogène
inhérents à l’existence de la plupart des
MS en Afrique.
Le premier choc a été la crise interne de
1997 : tentatives d’accaparement de la
MS par des responsables à des fins de
promotion individuelle, manquements
dans la gestion, divergences d’orientation
dans la conduite de la stratégie de
croissance de la MS.
En 2004, elle a fait face à un deuxième
choc : hausse des coûts de prises en charge
des membres suite à la modification
brutale et sans concertation de la grille
tarifaire de l’hôpital Saint-Jean de Dieu
(HSJDD) : l’unique prestataire de
santé privé avec qui la MS a signé une
convention.
En 2006, elle a été confrontée à un
troisième choc : effets pervers de la
politique de gratuité des soins accordée
aux personnes âgées de 60 ans et plus au
Sénégal (Plan Sésame). En effet, la mise
en œuvre de cette politique nationale peu
articulée avec les initiatives mutualistes
avait engendré chez certaines MS des
déperditions, la baisse des adhésions
et des incitations à cotiser chez les
personnes âgées, des déséquilibres
financiers, l’exacerbation des problèmes
de sélection adverse, l’effritement de la
confiance entre les mutualistes, etc.14
Enfin, depuis 2012, elle fait face
aux conséquences du retrait d’une
organisation non gouvernementale
(ONG) qui enrôlait, payait les cotisations
de 1 035 enfants et appuyait la MS dans le
renforcement de ses capacités humaines :
manque à gagner financier, problème de
disponibilité de ressources humaines.
La MS de Fandène a pu jusque-là résister
à ces différents chocs et continue à offrir
des prestations à ses membres alors que
d’autres MS qui ont été confrontées aux
mêmes défis et ayant des populations
cibles vivant dans des conditions
économiques relativement semblables
sont tombées en léthargie ou ont disparu.
52
Méthodes et données
Notre recherche qualitative est basée
sur une étude de cas unique. Les trois
instruments de collecte de données
mobilisés sont les entrevues individuelles
semi-dirigées, les focus groupes et
l’analyse documentaire.
La collecte s’est déroulée en 2012 et
2013. Celle de 2012 s’est focalisée sur
les hommes et femmes (membres et
ex-membres) de la MS âgés de 60 ans
et plus (dépositaires de la mémoire de
l’organisation) et les responsables de la
MS. Celle de 2013 avait pour objectifs de :
Approfondir les discussions,
diversifier les sources d’informations
en élargissant la population cible de
l’étude (jeunes, adultes hommes et
femmes âgées de 30 à 59 ans) ;
Recueillir des données administratives
et financières supplémentaires sur la
MS ; et
Documenter des faits qui n’avaient pas
été suffisamment investigués lors du
premier passage.
Les personnes qui ont participé aux
entretiens individuels n’ont pas été
invitées aux focus groupes.
Les données administratives de la MS
mises à notre disposition (registre de suivi
des membres, cotisations, réserves, coûts
des hospitalisations, analyses, chirurgie,
radios) ont été utilisées à des fins de
triangulation.
Ces différentes techniques de collecte des
données nous ont permis d’atteindre la
saturation de l’information.
Le tableau 1 résume les périodes de
collectes, le nombre d’entrevues et focus
groupes, leur durée, les lieux où ils se sont
tenus ainsi que certains sigles utilisés pour
le codage des transcriptions.
Le tableau 2 synthétise les thèmes abordés
lors des entretiens individuels et des
groupes de discussion.
Les données recueillies (wolof et français)
ont été retranscrites en français. Le
codage des thèmes a été réalisé à l’aide du
logiciel QDA Miner tout en nous donnant
une flexibilité pour prendre en compte
des nouveaux thèmes émergents.15 Une
analyse thématique des contenus a été
réalisée.
Résultats
Conditions de création
comme déterminants de
l’appropriation et de la
résilience la MS
La forte appropriation de la MS par ses
membres trouverait son fondement dans
les facteurs qui avaient motivé sa création
et le caractère endogène de l’initiative. Le
traumatisme collectif lié aux problèmes
d’accès financier et géographique aux
soins consécutif à la mise en œuvre
des politiques d’ajustement structurel
Tableau 1. Processus de collecte (entretiens individuel et focus groupes)
Périodes de
collecte
2012
2013
Nombre de
participants
Codifications
Durée
moyenne
Entretiens individuels
avec les femmes âgées
5
PAFN (N=1 à 5)
60 min
avec les hommes âgés
6
PAHN (N=1 à 6)
45 min
Responsables
1 focus group
5
FGRN (N=1 à 5)
1h 30
Membres hommes
(30–60 ans)
avec les hommes
7
EIHN (N= 1 à 7)
50 min
avec femmes
8
EIFN (N= 1 à 8)
1h 10
1 focus group avec
femmes membres
9
FGFN (N=1 à 9)
2h 35
Responsables de la MS
avec responsables MS
2
EIRN (N=1 à 2)
45 min
Jeunes
(18–30 ans)
1 focus group avec jeunes
10
FGJN (N=1 à 10)
1h 35
De Fandène (résident à
Dakar)
Ressortissants
3
EIREN (N=1 à 3)
1h
Cibles
Membres et non
membres
(60 ans et plus)
Membres femmes
(30–60 ans)
Mode collecte
s’appauvrit quand il est seul, mais unis
les pauvres s’enrichissent. Nous nous
sommes unis autour de la MS pour nous
enrichir » (EIH7).
Tableau 2. Principaux thèmes abordés
Histoire de la MS
•
•
•
•
Conditions et raisons de la création de la MS
Difficultés traversées par la MS (causes et conséquences)
Solutions (innovations économiques et sociales) mises en place
Leçons apprises
Confiance interpersonnelle
(horizontale) et
institutionnelle (verticale)
•
•
•
•
•
•
•
Entre les membres de la MS
Envers les non membres appartenant à la communauté
Envers membres et non membres n’appartenant pas à la communauté
Envers les gestionnaires de la MS
Envers les prestataires et professionnels de santé
En l’État et les structures qui le représentent
Aux ONG qui soutiennent les MS
Population cible, normes
sociales et valeurs
• Caractéristiques de la population cible
• Entre-aide et solidarité
•Réciprocité
Perceptions des membres
et des responsables par
rapport à la MS et ses
acquis
•Fierté
• Estime de soi
• Sentiment de contrôle
Gouvernance
• Répartition des pouvoirs au sein de la MS
• Modes de prises de décisions
•Participation
• Contrôle économique et social
Relations avec le prestataire • Perception de la qualité des services du prestataire conventionné et des
de services de santé et
établissements publics de santé (EPS)
perception de la qualité du
• Perception des coûts des services
service
• Évolution des relations entre la MS et le prestataire de service de santé (hôpital
privé Saint Jean De Dieu)
• Disposition des membres de la MS à aller se soigner dans les EPS
qui avait motivé les populations à créer
la MS est encore vif dans la mémoire
collective des populations de Fandène. Il
continue à influencer les rapports entre les
mutualistes et à régir leur perception par
rapport aux interventions des pouvoirs
publics.
Aussi le fait que la création de la MS
ait été initiée et portée conjointement
par l’église et par l’association des jeunes
de Fandène (étudiants, des cadres du
village) a favorisé son ancrage social. Ces
composantes de la communauté ont joué
un rôle décisif dans la sensibilisation, le
plaidoyer et l’enrôlement des habitants
dans la MS.
Un autre aspect important du démarrage,
qui a favorisé l’appropriation de la MS
par la communauté, est le consensus
qui se dégagea dès sa création sur ses
grandes orientations. Les populations
s’accordèrent sur le paquet de services que
la MS devait offrir et qu’elles estimaient
comme étant adéquats pour les couvrir
contre le risque maladie. L’accent a été
mis sur les dépenses de soins les plus
susceptibles de constituer une barrière
financière à l’accès aux soins ou de faire
basculer les membres dans la pauvreté
(hospitalisations, analyses, chirurgies etc.).
« Ce ne sont pas les petites dépenses au
poste (de santé) qui posaient les plus
grands problèmes donc les gens ne
voyaient pas la nécessité de créer une MS
pour ça » (PAF4).
Il y eut aussi consensus sur le choix du
prestataire conventionné et la durée
d’une période de carence (un an) entre la
date de création de la MS et le début des
prestations.
Caractéristiques de la
population cible et valeurs
favorables à la résilience de
la MS
La MS de Fandène est caractérisée par
une relative homogénéité de sa population
cible. La majorité de ses membres
s’identifie à une même ethnie (sérère), une
même religion (chrétienne), une même
histoire, une même lignée, un même
village. L’importance que les membres
de la MS du village accordent à l’intérêt
collectif et la nécessité de s’unir pour
faire face aux problèmes de santé de la
communauté apparaissent bien dans les
propos. « sans les autres, on ne peut pas ici
faire grande chose, une seule main ne peut
pas applaudir » (FGJ9). L’écart de revenu
serait relativement faible au sein de la
population. Tous ces facteurs ont favorisé
la mobilisation des villageois autour
des valeurs mutualistes de solidarité et
d’entre-aide communautaire. « Le pauvre
L’attachement à certaines valeurs comme
la fidélité et la dignité a été évoquée par
plusieurs participants pour motiver des
choix qui ont contribué à rendre la MS
plus résiliente à certains chocs. C’est
le cas des membres qui ont décidé de
garder leurs enfants dans la MS, malgré
des propositions d’une autre ONG
d’enrôler gratuitement ceux-ci dans une
autre MS suite au retrait de leur partenaire
traditionnel. « J’ai un devoir de fidélité
envers cette mutuelle et envers les gens
avec qui je suis. Je reste avec mes enfants
à Fandène même s’ils doivent payer »
(EIF8). Des personnes âgées de 60 ans
et plus ont évoqué des valeurs pour
expliquer leur choix de rester membres
de la MS malgré la mise en place du Plan
Sésame qui leur offrait la gratuité des
soins dans les établissements publics de
santé. « Pour moi, c’est un manque de
dignité, tu es avec des gens dans une
organisation, parce qu’il y a Sésame tu
t’en vas » (PAH5).
Aussi les liens sociaux de la population
cible de la MS favorisent une forme de
réciprocité qui a des effets qui dépassent
l’échange bilatéral. La réciprocité serait
ici plus large et ses effets plus diffus
donc facilement perceptibles dans toute
la communauté. Ainsi, les actions menées
par un individu au profit de la MS rendent
toute la communauté redevable à son
égard. De même, quand la MS vient en
aide à une personne, celle-ci et sa famille
se considèrent redevables envers toute la
communauté. « Ici puisque nous sommes
presque tous de la même famille. Tout ce
qu’une personne fait en bien bénéficie
indirectement à l’autre » (FGJ10). Ce
qui renforcerait la bonne perception par
rapport aux services rendus par la MS et
la nécessité de pérenniser la MS chez les
membres.
Relation avec le prestataire de
santé conventionné
La MS de Fandène et ses membres
entretiennent des relations particulières
avec l’HSJDD. « Ils nous ont soutenus
depuis le début et ça nous le retenons
jusqu’à présent ! » (PAF5). Il existait
diverses liens (confessionnels, parenté)
53
entre la population cible de la mutuelle,
les fondateurs de l’hôpital (église) et une
partie du personnel de santé. L’ancien
directeur de l’hôpital et certains membres
du personnel sont originaires du village
et/ou avaient des liens de parenté avec les
villageois. Ce qui a contribué à renforcer
le partenariat entre les parties. Les
participants à l’étude ont tenu cependant
à souligner que les raisons les plus
importantes de leur attachement à ce
prestataire sont liées à la qualité du service
(qualité de l’accueil, professionnalisme
du personnel de santé, absence de
tracasseries administratives, gratuité des
médicaments au cours de l’hospitalisation
avant le changement de la grille tarifaire,
etc.). « Il y a la qualité là-bas, ils sont plus
respectueux donc on a plus confiance au
personnel de santé qui est là-bas » (EIF6).
Aussi, des participants ont évoqué le fait
que les membres sont conscients que sans
la couverture totale ou partielle des coûts
des prestations sanitaires par la MS, les
tarifs des services qu’applique l’HSJDD
seraient hors de portée des bourses de
la plupart des ménages de Fandène. « Le
jour où il n’y aura plus de mutuelle ici, les
gens n’iront plus à Saint-Jean. Ça, tout le
monde le sait ici » (EIH4). La continuité
de la MS serait perçue ainsi comme une
condition à l’accès aux services de qualité
qu’offre l’HSJDD.
Confiance et conscience
critique
Les flexibilités accordées aux membres
(avances de fonds en cas d’hospitalisation,
les pratiques de certains membres
consistant à payer à l’avance plusieurs
mensualités de cotisation) sont des
indicateurs de l’atmosphère de confiance.
Elle favorise un sentiment de redevabilité
des bénéficiaires envers la MS et son
appropriation. Les responsables de la MS
qui ont pris les rênes du bureau après la
crise de 1997 bénéficient de la confiance
et de l’estime des mutualistes. « Nous
avons confiance en eux, il n’y a aucun
doute sur leur honnêteté » (EIH3).
Cette confiance entre les membres et
envers les gestionnaires de la MS contraste
avec leur défiance envers la pérennité des
politiques publiques et des interventions
de certains bailleurs de fonds extérieurs
visant à prendre en charge leurs besoins
de santé. Cette défiance pousse certains
54
membres à adopter des comportements
attentistes ou même à opter pour la non
utilisation de services gratuits dont le
recours est jugé, à terme, défavorable
à la pérennisation de la MS. « Ce qu’ils
(pouvoirs publics) nous proposent (la
gratuité des soins) c’est bien pour moi
mais si tout le monde y va ca tuera notre
mutuelle ... je ne suis pas sûr que ça va
continuer donc autant faire de telle sorte
que la MS continue en restant membre»
(PAH5).
La participation à la vie de la MS revêt
pour certains une grande importance. « Je
ne rate pas d’AG. Je tiens à être là quand
on prend les décisions et faire valoir mes
positions» (PAH1). Cette exercice du
droit de donner son avis contribuerait à la
vitalité démocratique dans la MS et serait,
selon certains, la principale raison de
l’adhésion des membres aux décisions et
à leur mise en œuvre. « Les gens adhèrent
aux décisions parce qu’ils savent que leurs
avis sont pris en compte » (EIF4).
L’adoption de comportements semblables
expliquerait la moindre vulnérabilité de
la MS de Fandéne aux effets pervers
de certaines interventions ou retraits
d’ONG. En effet, la tendance de certaines
ONG à imposer leur vision, le caractère
déstructurant de leurs interventions sur
certaines initiatives communautaires
locales, leurs stratégies d’implantation
et de retrait, leur manière d’impliquer les
populations dans l’élaboration et la mise
en œuvre des projets, la méconnaissance
des réalités socio-culturelles du terrain de
certaines d’entre elles ont été décriés par
plusieurs participants. « ... Il ne faut pas
que leur aide vienne gâter les formes de
solidarité qui sont là » (PAH6).
Les femmes sont représentées dans
les organes décisionnaires de la MS
et participent activement à la vie de la
MS. Elles sont le lien entre la MS et les
familles pour la collecte des cotisations
et les campagnes de sensibilisation. « Le
jour de la collecte des cotisations, on ne
voit défiler ici quasiment que des femmes.
Elles ont fait de la MS leur affaire »
(EIR1). Elles auraient un avantage
comparatif sur les hommes au niveau
de l’information sur le fonctionnement
de la MS, ce qui rend leur présence
aux réunions nécessaire. « Quand la
mutuelle a des problèmes, nous sommes
les premières à être au courant….C’est
normal qu’ils (les hommes) tiennent à
notre présence aux réunions pour en
savoir davantage » (FGF3). Le fait que
la trésorière soit une femme ne serait pas
étranger à la place centrale qu’occupent
les femmes dans la MS.
Gouvernance
L’Assemblée Générale (AG) de la MS de
Fandène dispose d’importants pouvoirs
et les exerce de manière effective. Les
gestionnaires de la MS ont peu de marge
de manœuvre pour changer les grandes
orientations stratégiques de l’organisation
(par exemple, l’élargissement de la MS
à d’autres communautés, la négociation
de nouvelles conventions avec d’autres
prestataires etc.). « Le bureau procède
par projet de décision. Ils (responsables)
n’ont pas le droit de prendre des décisions
qui engage l’avenir de la MS quel que
soit l’urgence. Ils proposent et consultent
l’AG. Les gens en discutent, adoptent ou
refusent » (FGF5).
La reddition des comptes est une règle
inaliénable. « Lors des AG, les responsables
de la MS ne se font pas prier pour dire aux
gens là où chaque centime de la MS est
passé » (FGF5). Le contrôle social plus
traditionnel s’exerce parallèlement à celui
du contrôle budgétaire moderne. « Tout
ce qu’une personne fait dans le village
sera su » (EIF8).
La question du prolongement des rapports
de force existants dans la communauté et
ses éventuels effets sur le processus de
prise de décision au sein de la MS n’a pas
été approfondie lors de nos entretiens.
Cependant, les commentaires de certains
participants laissent apparaitre le caractère
horizontal des rapports sociaux dans la
répartition des pouvoirs au sein de la MS.
« Nous sommes tous membres au même
pied d’égalité, nous payons les mêmes
cotisations, nous avons les mêmes soins
quand nous allons à l’hôpital, nous avons
le même droit à la parole » (EIH4).
Faiblesses de la MS
Les propos recueillis durant les entrevues
mettent en évidence certaines faiblesses
(réelles ou potentielles) de la MS.
La contractualisation avec un seul
prestataire (hôpital privé) et la refus de
certains membres d’aller se soigner dans
les établissements publics (moins chers)
posent des risques d’inefficience dans
l’utilisation des ressources de la MS et
d’augmentation des co-paiements chez
les membres. À ce niveau, la gouvernance
de la MS est problématique. En effet, les
responsables de la MS nous ont confié
n’avoir aucun pouvoir sur la décision
d’établir des contrats avec les structures
de santé publiques. C’est une prérogative
de l’AG. Cette décision n’a jusque-là
pas reçu l’adhésion de la majorité. Les
initiatives prises par les responsables
visant à inciter les membres à s’orienter
vers le public (remboursements sur
présentation de factures reçues suite aux
visites dans les établissements publics de
santé) en s’appuyant sur la convention
cadre de la coordination régionale des MS
de la région se sont soldées au mieux par
des résultats mitigés.
Les membres ont jusque-là opté pour un
enfermement stratégique de la MS qui
restreint sa clientèle cible à la communauté
de Fandène et la condamne à demeurer de
taille modeste. Les responsables de la MS
reçoivent des demandes d’adhésion de
personnes qui vivent aux alentours de
Fandène mais l’AG est encore réticente
à toute idée de l’élargir à certains
demandeurs jugés « éloignés du village ».
« J’ai des sollicitations de personnes en
dehors du village qui veulent venir mais je
n’ai aucun pouvoir dans ce domaine, c’est
à l’AG de décider » (EIR1).
Les principales raisons évoquées par les
membres pour justifier leurs positions
sont :
Les échecs qu’auraient connus certaines
MS dans ce domaine. « Nous savons ce
que l’élargissement à outrance a couté
à la mutuelle X, ils sont au bord de la
faillite » (FGF5).
Certains membres ne sont pas
convaincus de la corrélation positive
entre le nombre de membres d’une
MS et sa performance. « Ce n’est pas
en réunissant beaucoup de mancheaux
qui n’ont rien de commun qu’on fait
avancer le décorticage d’une récolte »
(PAF1).
Le désir de garder le contrôle
économique et social sur leur MS.
Les appréhensions quant au niveau
d’appropriation et de priorité
qu’accorderaient les « nouveaux
arrivants » à la MS. « Ici les gens
connaissent l’intérêt de la MS à tel
point qu’ils en font une obligation,
nous ne sommes pas sûr que ça sera
le cas de ceux qui viendront après »
(FGF3).
Les problèmes de sélection adverse et
d’aléas moral et de recouvrement des
cotisations et dettes que pourrait poser
l’élargissement de la MS.
Bien que minoritaires, des voix
discordantes se sont élevées durant
nos entrevues individuelles et focus
groupes pour relever que l’attitude des
« récalcitrants à l’élargissement » de la MS
témoigne d’un « manque d’ouverture ».
Ils estiment que la plupart des arguments
de ces derniers sont basées sur des
« préjugés ». « Si on ne donne pas aux
gens la chance d’adhérer, comment peuton savoir qu’ils sont de bons mutualistes
ou pas » (EIH7).
La MS est confrontée à des faiblesses
structurelles auxquelles font face la
plupart des mutuelles : l’égalité des
cotisations quel que soit le niveau de
revenu du membre et le bénévolat dans la
gestion de la MS, ce qui pose un problème
d’équité du système et d’attractivité et de
disponibilité de ressources humaines de
qualité pour la gestion de la MS.
Une autre source de faiblesse est liée aux
conséquences que pourrait engendrer
l’un des mécanismes de solidarité mise
en place par la MS : les avances de fonds
pour couvrir les dépenses des membres
en cas d’hospitalisation prolongée.
Bien qu’avantageux à plusieurs points
de vues, ce dispositif pourrait pousser
les mutualistes, notamment les plus
pauvres, à rentrer dans un cycle durable
d’endettement duquel certains auront du
mal à s’extirper.
Discussion
La discussion des principaux résultats est
faite sous le prisme des enseignements
qui peuvent en être tirés pour la mise en
œuvre de la stratégie sénégalaise de CMU.
Implication des communautés
dans la création des
mutuelles de santé
L’expérience de Fandène montre que
le fait que l’initiative de sa création soit
endogène (portée par les membres
de la communauté et des leaders
communautaires) a été décisive dans la
réussite de sa mise en place, l’adhésion des
populations, la résilience et la pérennité
de l’initiative. Ce résultat confirme les
conclusions de Dubois 11 pour qui la
participation de personnes influentes
impacte positivement sur l’adhésion aux
MS. À l’inverse, il ne semble pas aller dans
le même sens qu’une étude9 réalisée dans
la région de Thiès selon laquelle il y a un
très faible pourcentage des membres qui
adhérent en raison de la participation d’un
leader communautaire.
Le rôle que jouent (ou que pourraient
jouer) les guides religieux et coutumiers
dans la création des MS en Afrique de
l’Ouest, l’impact de leurs interventions sur
leur pénétration, résilience et pérennité et
in fine sur l’atteinte des objectifs de la
stratégie nationale d’extension de la CMU
devrait davantage être investigués compte
tenu de la place centrale qu’occupent ces
leaders dans ces pays.
Les cercles vertueux
La confiance dans ses différentes
dimensions est un déter minant
important de la réussite ou de l’échec
des MS.6,16 Nos résultats montrent que la
confiance relativement élevée qui règne
entre les différents acteurs (membres,
responsables, professionnels de santé
de l’HSJDD) a contribué à installer la
mutuelle dans un cercle vertueux. Elle a
eu des effets positifs sur le développement
de valeurs mutualistes (entre-aide,
solidarité, sentiment d’être redevable,
réciprocité etc.). Les interactions qui en
ont résulté ont favorisé l’appropriation et
l’ancrage social de la MS qui eux-mêmes
favorisent sa résilience et sa pérennité.
Ces dernières rétroagissent à leur tour
positivement sur la confiance entre les
acteurs et contribuent à renforcer la MS.
Vue sous cet angle, l’expérience de la
MS de Fandène vient conforter la thèse
de Fukuyama17 selon laquelle un niveau
de confiance élevé entre individus serait
propice à la multiplication des relations
sociales qui, en rétroaction, alimenteraient
le niveau même de confiance sociale et les
performances des organisations.
Dans le domaine de la gouvernance, la
MS de Fandène a su mettre en place un
dispositif qui favorise la participation
des membres aux principales décisions et
55
circonstances, l’une des clés du succès
des politiques publiques d’extension de
la CMU par la promotion des MS est la
restauration ou la création de conditions
pour des relations durables de confiance
entre les pouvoirs publics, les partenaires
techniques et financiers, d’une part, et
les populations cibles des MS, d’autre
part. Aussi, les pouvoirs publics devraient
agir sur les leviers qui promeuvent la
bonne gouvernance, la participation
démocratique, l’autonomie des MS et la
bonne articulation entre les politiques de
gratuité et de promotion des MS et un
bon équilibre entre le contrôle social et
judiciaire pour favoriser la réussite de la
stratégie de la CMU à travers les MS.
orientations, une organisation basée sur
le consensus et la transparence dans la
gestion. L’aversion des membres à toute
tentative d’accaparement de la mutuelle
par un individu ou groupe, l’attachement
des membres à l’autonomie de leur
organisation ainsi que la perception de
l’égalité en droits et en devoir chez les
membres illustrent, à bien des égards, le
caractère horizontal plutôt que vertical des
liens sociaux qui régissent la marche de la
MS. L’expérience de la MS de Fandène
concorde bien avec la thèse de Putnam18
selon laquelle le niveau de capital social
élevé va de pair avec une société ou
une communauté où les relations sont
davantage horizontales et démocratiques
que hiérarchiques et autoritaires.
Le modèle de Fandène montre que la
gouvernance, la confiance interne et
la participation seraient liées et leur
interaction contribuerait à consolider
l’appropriation et l’ancrage social et, par
conséquent, sa résilience et sa pérennité.
La relative bonne gouvernance de la MS
ne devrait cependant pas faire perdre de
vue quelques-unes de ses failles et les
problèmes que celles-ci engendrent. Parmi
ceux-ci, il y a la faible marge de manœuvre
du bureau exécutif dans la signature
de convention avec des établissements
publics de santé, le recrutement de
56
nouveaux membres en dehors de Fandène
et certains effets pervers du contrôle
social et du capital social. Un optimum
entre un bon contrôle politique de la MS
par les membres d’une part, et une gestion
rationnelle et efficiente (nécessitant les
inputs des gestionnaires) d’autre part est
nécessaire pour l’utilisation judicieuse des
ressources et la consolidation des acquis
de la MS. De même, le contrôle social
en place prévient les comportements
déviants (détournements des deniers
de la MS, sélection adverse, aléa moral),
mais le risque est que la communauté
veuille aussi contrôler l’utilisation des
services de l’hôpital des membres. Or,
elle n’a pas les compétences nécessaires
pour juger du caractère approprié ou non
d’une utilisation des services de santé d’un
membre. La confidentialité des dossiers
médicaux doit être préservée. Sur ces
aspects de la gouvernance de la MS, il faut
s’assurer que les balises sont respectées
pour que justement tout le monde ne
sache pas tout surtout s’il s’agit de la santé
des membres.
Confiance externe et passage
à l’échelle
Nos résultats suggèrent une défiance
des membres de la MS par rapport à la
pérennité des interventions de l’État et
de certains bailleurs de fonds. Dans ces
À Fandène, certains effets indésirables du
capital social qui poussent les membres
à être réticents voire hostiles à « jeter
un pont vers l’extérieur (personnes
ou groupes différents) ».19 Les critères
d’exclusion (explicites et implicites) à
l’adhésion à la MS reflètent, à bien des
égards, ce que certains auteurs qualifient
de côté sombre du capital social, « the dark
side of social capital ».20,21 L’enfermement
stratégique de la MS ne semble pas encore
avoir compromis la viabilité de la MS et
semble même, sur certains plans, avoir
favorisé la solidarité entre les membres,
sa résilience et sa pérennité. Mais il la
condamne à demeurer de taille modeste
et à composer avec les avantages mais
aussi les inconvénients d’une MS de
taille modeste. Pour contribuer de façon
décisive à la CMU, la MS devra élargir
sa base d’adhésion à une échelle plus
grande qu’un village tout en préservant les
acquis qui lui ont permis d’être résiliente
et pérenne.
Qualité des soins
La relation entre l’HSJDD et la MS est une
autre donnée probante de la pertinence
d’offrir des services de qualité dans les
établissements publics de santé pour
favoriser l’attractivité, l’appropriation
des MS et étendre la CMU auprès des
populations. L’offre de soins de qualité
et des relations de confiance entre les
membres d’une MS et le personnel du
prestataire de santé conventionné ont été
déterminantes dans l’appropriation, la
résilience et la pérennité de l’organisation.
Les membres de la MS ont délaissé
les établissements publics de santé,
notamment de première ligne, au profit
de cet hôpital privé pour des raisons
principalement liées à la qualité des soins.
Notons cependant, que la perpétuation de
tels comportements d’utilisation des soins
parallèlement à la hausse des mutualistes
(subséquente à la mise en œuvre de la
stratégie nationale d’extension de la
CMU à travers les MS) risque de créer
des dysfonctionnements au niveau des
paliers supérieurs de la pyramide sanitaire.
Par ailleurs, le cas de Fandéne semble
être symptomatique de certains effets
pervers que l’assurance maladie peut
provoquer sur l’efficience du financement
de la santé.22 Wagstaff et al22 soulignent
que l’assurance maladie peut accroître les
paiements directs ainsi que les risques
de dépenses de santé catastrophiques en
conduisant les ménages à rechercher plus
fréquemment des soins, plus onéreux,
auprès de prestataires de rang plus élevé
dans la pyramide sanitaire.
Il serait nécessaire de mettre en place
des balises pour favoriser l’utilisation des
services de première de ligne.
Les activités des bailleurs de fonds dans ce
domaine devraient être mieux encadrées
pour que leurs modes d’intervention et de
retrait ne nuisent pas aux initiatives locales
comme indiqués par nos participants.
Limite de l’étude
Le risque de biais de désirabilité sociale
était réel. Pour les prendre en compte,
nous avons pris le soin d’insister sur notre
indépendance par rapport à l’État et aux
partenaires internationaux en précisant à
toutes les personnes qui ont participé aux
entrevues, focus groupes et séances de
travail que l’étude était réalisée à des fins
strictement académique et scientifique.
De plus, certaines spécificités de la
MS et de sa population cible rendent
certaines de nos conclusions difficilement
généralisables. Sur ces points, la validité
externe de notre étude est relativement
limitée.
Conclusion
Les causes de la résilience et de la
pérennité de la MS de Fandène sont
multidimensionnelles. La vision
strictement économique et financière
n’aurait pas permis de saisir toutes les
facettes liées à son développement. Leur
compréhension nécessite la prise en
compte de toute la richesse et complexité
des dynamiques de sa création et de son
développement. Il en est ainsi pour
la plupart des MS en Afrique, d’où la
nécessité de les prendre en considération
pour diminuer leurs risques d’échecs et
augmenter leur performance et pérennité.
La MS de Fandène a favorisé la solidarité
et la mutualisation des risques et facilité
l’accès des populations à des soins de
qualité. Cependant, certaines de ses
faiblesses mettent en exergue le fait
qu’il sera difficile d’atteindre la CMU
si l’adhésion aux MS reste volontaire,
si la mutualisation des fonds se fait à
petites échelles et si les effets pervers de
l’assurance maladie sur l’utilisation des
services de santé des mutualistes ne sont
pas maitrisés. À terme, la CMU obligatoire
et le financement des contributions des
indigents par le gouvernement nous
semblent être la voie la plus indiquée
pour assurer une couverture adéquate,
équitable et pérenne de la majorité de la
population.
Néanmoins, le cas de Fandène montre
que cette organisation a acquis au fil
des années une crédibilité auprès de
sa population cible. Cela fait d’elle un
partenaire légitime de l’État auprès de ses
membres pour la CMU. La question est
de savoir quel est le meilleur dispositif à
mettre en place pour assurer une meilleure
contribution de ces organisations dans la
transition vers la CMU obligatoire. p
Remerciements
Éthique : L’étude a obtenu une autorisation du comité
d’éthique du centre de recherche du centre hospitalier de
l’université de Montréal (CR-CHUM) et d’un comité ad hoc de
la coordination régionale des mutuelles de santé de Thiès
(CRMST) au Sénégal en 2012.
Financement : Bourse postdoctorale dans le cadre du
programme Teasdale Corti (Financement du centre de
recherches pour le développement international du Canada,
Initiative de recherche en santé Mondiale).
laissés-pour-compte des régimes d’assurance maladie ?
Oxford: Oxfam International 2013.
4. Ekman B. Community-based health insurance in lowincome countries: a systematic review of the evidence.
Health Policy Plan 2004; 19(5):249–270.
5. Defourny J, Faillon J. Les déterminants de l’adhésion
aux mutuelles de santé en Afrique subsaharienne :
un inventaire des travaux empiriques. Mondes en
développement 2011; (1)153:7–26.
6. Waelkens MP, Criel B. Les mutuelles de santé en Afrique
subsaharienne. État des lieux et réflexions sur un agenda de
recherche. HNP Discussion Paper. Washington, DC: World
Bank 2004.
7. De Allegri M, Sanon M, Sauerborn R. To enrol or not
to enrol? A qualitative investigation of demand for
health insurance in rural West Africa. Soc Sci Med 2006;
62(6):1520–1527.
8. Schneider P. Trust in micro-health insurance: an
exploratory study in Rwanda. Soc Sci Med 2005;
61(7):1430–1438.
9. Jütting JP. Health insurance for the poor in developing
countries. Aldershot, UK: Ashgate Publishing 2005.
10. Ouimet MJ, Fournier P, Diop I, Haddad S. Solidarity or
financial: An analysis of the value of community-based
health insurance subscribers and promoters in Senegal.
Canadian J Pub Health 2007; 98(4):341–346.
11. Dubois F. Les déterminants de la participation aux mutuelles
de santé : étude appliquée à la mutuelle Leeré Laafi Bolem de
Zabré. Unpublished masters thesis (DES in management
development). Belgium: Université de Liège 2002.
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evaluation of voluntary, non-profit insurance schemes
with case studies from Ghana and Cameroon. Soc Sci Med
1999; 48(7):881–896.
13. Basaza R, Criel B, Van der Stuyft P. Community health
insurance in Uganda: Why does enrolment remain low? A
view from beneath. Health Policy 2008; 87:172–184.
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charge sanitaire des populations : le cas des mutuelles de
santé de la région de Thiès (Sénégal). Rapport de recherche,
Montréal, CR-CHUM 2012; 45.
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Montréal : Presse de l’Université de Montréal 1996.
16. Ridde V, Haddad S, Yacoubou M & Yacoubou I. Exploratory
study of the impacts of mutual health organisations on
social dynamics in Benin. Soc Sci Med 2010; 71(3):467–474.
17. Fukuyama F. Trust: Social Virtues and the Creation of
Prosperity. New York: Free Press 1995.
18. Putnam R-D. Making Democracy Work: Civic Traditions in
Modern Italy. Princeton: Princeton University Press 1993.
19. Woolcock M. Social capital and economic development:
Toward a theoretical synthesis and policy framework.
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international perspective. Oxford: OUP 2001; 159–174.
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Références
1. Ministère de la santé et de l’action social du Sénégal.
Rapport introductif du conseil interministériel sur la
couverture maladie universelle. Dakar 2013.
2. Soors W, Devadasan N, Durairaj V and Criel B. Community
health insurance and universal coverage: multiple
paths, many rivers to cross. World Health Report 2010.
Background Paper 48. Geneva: WHO 2010.
3. Oxfam International. Couverture santé universelle :
Pourquoi les personnes en situation de pauvreté sont les
57
A
Increasing equity among
community-based health
insurance members in
Rwanda
Joséphine Nyinawankunsi,i Thérèse Kunda,ii Cédric Ndizeye,ii Uzaib Sayaiii
Corresponding author: Thérèse Kunda, e-mail: [email protected]
C
SUMMARY—The community-based health
insurance (CBHI) scheme launched by the
Government of Rwanda (GoR), reached 91%
of the population in 2010, starting from 7%
in 2003. Initially, all CBHI members paid the
same fees, regardless of their personal income,
and the poorest citizens faced challenges in
paying premiums (almost US$ 1.50 per person).
A mechanism was thus urgently needed to
guarantee access to health care for the most
vulnerable and promote equity among members.
The GoR decided to introduce a stratification
system based on the socioeconomic status of the
population, referred to as Ubudehe. Together with
partners, including the Integrated Health Systems
Strengthening Project (IHSSP), the GoR developed
a national database that stratifies Rwandan
citizens by income. To date, more than 10 million
residents’ records, representing 96% of Rwanda’s
population, have been entered into the database.
This database helped identify the most vulnerable
based on socioeconomic status (about 25% of the
population). Identification of the poorest among
the population has allowed an increase in CBHI
funds due to identification of individuals who
have a greater capacity to pay. The database thus
improved the financial viability and management
capacity of the CBHI scheme.
entral to the Government of
Rwanda’s strategy to become
a middle-income country by
2020, as per Vision 2020 as well as the
Economic Development and Poverty
Reduction Strategies from 2008 to 2018
(EDPRS and EDPRS 2), is the laudable
goal of universal access to health care.
The strategy of the Rwanda Ministry
of Health (MINISANTE or MoH) to
realize this goal is three-pronged within
a revamped, decentralized system, and
includes performance-based financing
(PBF) to incentivize improved service
delivery, quality improvement initiatives
at the health-care delivery levels, and the
implementation of wide-scale national
health insurance to defray the cost of
care for the poorest. The strategy is
engendered through a series of laws
covering various aspects of social health
protection.1
Rwanda’s CBHI scheme (commonly
known as mutuelles de santé) is one of the
largest public health insurance schemes in
sub-Saharan Africa. CBHI schemes can be
broadly defined as voluntary prepayment
plans for health care that operate at a
community level; in the case of Rwanda,
CBHI is a national-level scheme. The
Government of Rwanda (GoR) first scaled
up its CBHI policy in 2004 after initial
pilots in 1999 to cover patient costs for
curative services. Today, it is heralded as
one of the most successful in Africa, after
expanding coverage from less than 7% of
the population in 2003 to 91% in 2010.2,3
58
i Ministry of Health, Rwanda
ii Rwanda Integrated Health Systems Strengthening Project, Rwanda
iiiCenter for Health Services, Management Sciences for Health, United States of America
The decentralized health system in
Rwanda consists of mutuelle sections in
nearly all health facilities where members
are entitled to a comprehensive list of
curative and preventive services; CBHI in
Rwanda focuses mostly on provision of
services to people in the informal sector
and aims at providing them equitable
access to quality health services on
payment of annual membership fees.
Health facilities are then reimbursed for
the services they have provided based
on fee-for-service upon submission of
monthly invoices, which are audited
before payment and also by capitation
whereby the provider receives a fixed
amount for each enrolled member for a
given annual reference period.
A change in mutuelle policy in April 2010
brought into focus universal and equitable
access to quality health services for all,
and introduced a new CBHI premium
schedule using a system of stratification.
To reach this goal, the policy was based
on principles of solidarity and equity.
Previously, contributions of households
to “mutuelles” were not based on their
ability to pay (they were based on a
flat rate premium), and were therefore
strongly regressive – considered by the
World Health Organization as unfair,
and to some degree excluded the poor
in the informal sector. The 2010 mutuelle
policy stated, “CBHI complements
other existing social insurance systems,
such as RAMA and MMI, in addition to
private insurance schemes which target
workers from the formal and private
sector of the economy. To reach this
goal, the development policy is based
on principles of solidarity and equity.”4
Even though enrolment and utilization
of services had been increasing up to
this point at the outpatient level, there
was a clear need to improve equity among
patients accessing services. In particular,
many patients were roaming between
health facilities for services – either due
to travel or convenience. This made it
difficult to verify the membership status
of individuals before providing treatment.
There was thus a need to differentiate
patients based on their ability and capacity
to pay premiums into the CBHI scheme.
poor. Between 2010 and 2011, at the
request of the MoH and Rwanda
Ministry of Local Government and
Internal Affairs (MINALOC) and its
Common Development Fund (CDF),
the USAID-funded Integrated Health
Systems Strengthening Project (IHSSP)
designed a national income categorization
database (based on ubudehe – the deeprooted Rwandan practice and culture of
collective action and mutual support to
solve problems within a community) to
store information on the population’s
socioeconomic status.5 Information on
every Rwandan household was collected
through the support of the CDF,
which is a government-owned fund
set up to support the implementation
of decentralization policy, and also
through the support of MINALOC’s
Ubudehe Programme which is a GoR
initiative to help Rwandans “create social
capital, nurture citizenship and build a
strong civil society”. In 2001, Ubudehe
was reintroduced into Rwandan life by
the Rwanda Ministry of Finance and
Economic Planning (MINECOFIN) in
partnership with MINALOC as a way
to better involve communities in their
development by setting up participatory
problem-solving mechanisms. The
Ubudehe Programme functions at the
level of the decentralized administrative
entity nearest to the recipients, at the
cell or village level. CBHI is coordinated
at the district level, where each of the
30 districts has a pooled-risk fund; each
CBHI section has a health centre; and
One of the most important aspects
in Ubudehe is assigning all Rwandan
households into one of six categories,
based on income and assets. Results have
shown that the Ubudehe Programme appears
to be largely relevant and consistent with
the policies of the Rwandan Government
Figure 1. Structure of CBHI
Ministry of
Finance
Ministry of
Health
Rwanda Health
Insurance Council
Private Health
Insurance
Regulation
Rwanda Social
Security Board
+ MMI
National Risk
Pool
Referral
Hospital
District
District CBHI
Risk Pool
District
Hospital
Sector
CBHI Section
Health
Centre
Finance
Payment
Advisor
This article describes the operationalization of national policies that introduced
stratified premiums based on Rwandans’
ability to pay to better target the
all villages have a CBHI mobilization
committee. Monetary contributions from
members are received at the community
level, and used to reimburse health centres
for services rendered. Each section
covers a defined area and population,
and includes one health centre where
CBHI members are entitled to receive
services from the minimum package of
activities (MPA). Some 55% of premium
contributions remain at the section level
and 45% of each section’s premium
contributions are paid into a district
risk pool and are used to reimburse
district hospitals for services provided
to members under the comprehensive
package of activities (CPA). Finally, 10%
of these contributions into the district
risk pool are transferred to a national
risk pool to cover services provided at
the referral hospital level. For indigent
populations (classified as Category 1 in
the CBHI system), the Government of
Rwanda and development partners pay
insurance premiums to the appropriate
section risk pool and their co-payments
are waived. Service providers at health
centres are paid on a fee-for-service basis
upon submission of monthly invoices,
which are audited before payment.
Population
Source: Rwanda MoH, CBHI Policy, 2010
59
IHSSP supported the stratification
and data-entry process for a database
containing over nine million records
classifying all Rwandan households
into socioeconomic categories. These
data were subsequently used in CBHI
membership management processes and
various other government programmes.
The Ubudehe database was also updated
with spreadsheets from each of Rwanda’s
14 000 villages. The goal of this exercise
was to derive a contribution system for
CBHI that assures equity and solidarity
among its members, as well as improved
financial viability for the CBHI scheme
so as to protect the poor from the burden
of covering the rich at the same level.
Additionally, this database has proved to
be a tool that planners and actors in other
development programmes could use to
increase equity, particularly in targeting the
poorest part of the Rwandan population
for improved social protection.
The goal of the CBHI scheme is to
cover the 95% of the population in the
informal sector, with a specific focus
on those in rural areas. As mentioned
above, a critical element of Rwanda’s
CBHI structure is the involvement of
and linkages between each level of the
health system, (see Figure 1). These
linkages have facilitated the success of the
programme in improving access among
citizens, but the 2010 policy change in the
mutuelle recognized that better targeting of
the most vulnerable needed to occur in
order to provide equitable care.
Beginning in 2006, each household paid
a premium of 1 000 RWF (US$ 1.50) per
member of the household.7 Utilization
levels (number of visits per capita per
year) increased, as shown in Figure 2,
primarily at the outpatient level from
2003 to 2010, and enrolment similarly
increased at a steady rate. Previously,
findings suggested that CBHI enrolees
in the poorest quintiles had two times
lower utilization and two times higher
catastrophic payments, compared with
those in the highest quintiles.8 As a result,
it became all the more vital to improve
targeting of CBHI subsidies from the
government and development partners to
the poorest in the Rwandan population.
60
Figure 2. Enrolment into CBHI and outpatient utilization, 2003–2010
Enrolment in CBHI
(%) Percentage
fin fighting poverty and developing the
country’s economy.6
Utilization rate (OPD utilization)
100
90
80
70
60
50
40
30
20
10
0
2003
2004
2005
2006
2007
2008
2009
2010
7%
31%
27%
39%
44%
47%
73%
61%
75%
72%
85%
83%
86%
86%
91%
95%
Source: CBHI Annual Report, MoH, 2011
Methods
To improve equity within the CBHI
system, in 2009 the MoH worked
closely with the IHSSP to re-design the
insurance system’s payment structure. In
the revised scheme, the population of
Rwanda pays into the system on a sliding
scale, based on their household assets.
The highest and middle groups pay an
annual fee by household: 7 000 RWF
(US$ 10.50) and 3 000 RWF (US$ 4.50),
respectively – plus a small co-payment
at health centres and are responsible
for 10% of the cost of care at referral
facilities. The 25% of Rwandans with
the fewest assets do not pay for their
insurance and are not charged for
health services at any public facility. The
government believed that this system
would ease the financial burden enough
so that all Rwandans could access health
services, and at the same time raise
sufficient funds to finance quality service
delivery throughout Rwandan facilities.
Before the new scheme could be
implemented, the ministry had to
determine the financial status of each
household, a difficult prospect in a
country where as much as 90% of
the labour force works in subsistence
agriculture and the informal economy.
MINALOC had data on the assets held
by each of the country’s 1.8 million
households, but records were all on paper.
To use the information, it would need to
be computerized.
In collaboration with the MoH, IHSSP
designed and built a database to house
the information and recruited a data entry
team of 500 people who worked in shifts,
16 hours a day. The intensive process took
just three months, and, by January 2011,
90% of the data had been entered into the
system and households were assigned to
the lowest, middle or highest economic
bracket.
Because the management of the CBHI
system is so well decentralized – there
is a CBHI office in each health centre
in charge of enrolment for the facility’s
catchment area – Rwandans enrolled in
the new system rapidly. By September
2012, 90% of Rwandans eligible for
CBHI were enrolled. Soon, Rwandans
were not just enrolled in the health
insurance plan, they were using it.
The National Income Categorization
Database (NICD) was used to enable
local government authorities at the sector
level to collect data on income categories
of Rwandans by household. Data for this
exercise were collected in two phases at
the village level, during which individuals’
identities were confirmed against their
official identity cards. These data were
subsequently compiled at the sector
and cell levels, and entered into online
databases at the district levels.
At the request of the MoH, IHSSP
also used this database to conduct
various data analyses, and supported the
upgrade and maintenance of PBF and
CBHI application systems. The Health
Management Infor mation System
(HMIS) team assisted the ministry in the
introduction, customization and rollout
of the District Health Information
System 2 (DHIS-2), which is the new
Rwandan HMIS system, and ensured that
it is fully functional and used successfully.
Validations of these data were conducted
in 2011 on a sample of one sector per
province and also in Kigali City. The
main objective of this activity was to
corroborate the data and to evaluate if
the population agreed with attributed
categories in relation to the new policy
of “mutuelle de santé” scheme of payment.
A Delphi method was employed during
these validation meetings, during which
missing households were identified and
attributed to their respective category.
Multiple administrative structures were
involved in this exercise, including
those at the central (such as MoH and
MINALOC), district, sector and cell
levels. At the village level, community
leaders participated in the organization
of meetings with community members.
In each of the five sectors, all cells were
considered for validation, but in each
cell, only two villages were taken into
account. In total, the validation exercise
was conducted in 48 villages. From the
Ubudehe social stratification database,
it was confirmed that these villages
comprised 6 224 households and 27 789
individuals. In order to correct and
confirm the Ubudehe categories, in-person
visits were made by the supervising team
to households that disagreed with the
attributed category.
Once the data were collected at the
household level, they were categorized
into CBHI categories so as to form the
basis of premiums payable to the CBHI
system.
Results
Data were entered into a web-accessible
social stratification database containing
the records of nearly nine million
Rwandans. The database was jointly
coordinated by MINALOC through
the community-based collective action
programme (Ubudehe), and MoH through
the CBHI scheme. Data were gathered
across all 30 districts, from almost 14
747 villages (99.3%) – 8.9 million people
across Rwanda (86.10% of the total 10.3
million population).9 In recent years, this
has increased to almost 96% of the whole
population.
As shown in Figure 3, a majority of
the population stratified through this
exercise in 2010–11, or 42.4% of the total
population sampled in the stratification
exercise, belonged to Ubudehe Category
III (“the poor”), followed by 21.9% from
Figure 3. Results for Ubudehe and CBHI categorization in Rwanda, 2011
Ubudehe category
CBHI category
Category IV (“resourceful poor”) and
19.5% from Category II (“very poor”) of
the total population.
Consequently, the implementation of the
new CBHI policy was made possible with
more than 86% of the population that had
their socioeconomic information available.
As a result of the categorization of
Rwandans according to ability to pay
based on their Ubudehe categories, citizens
began to pay premiums on a sliding scale
based on their household assets. From a
flat premium of 1 000 RWF person (or
2 500 RWF per household), the pricing
of the CBHI premiums evolved to a
system based on the household’s Ubudehe
category or their proxy ability to pay
(Table 1).
Table 1. Ubudehe population and
CBHI categories
CBHI
Premium per
household per
year
Ubudehe I & II
Category 1
2 000 RWF
Ubudehe III & IV
Category 2
3 000 RWF
Ubudehe V & VI
Category 3
7 000 RWF
Ubudehe population
Source: CBHI Annual Report 2012–13
The wealthiest and middle groups
(classified as categories 3 and 2 of CBHI,
respectively) began to pay an annual fee
of 7 000 RWF (US$ 10.50) or 3 000
RWF (US$ 4.50) per person, respectively.
As depicted in Figure 3, 65% of the
population was categorized into CBHI
Category 2 as a result of the Ubudehe
stratification.
Discussion
Category I (5%)
Category II (20%)
Category III (42%)
Category IV (22%)
Category V (4%)
Category VI (1%)
Uncategorized (7%)
Category I (25%)
Category II (65%)
Category III (5%)
Uncategorized (7%)
This stratification exercise based on the
Ubudehe system has formed the basis of
premiums payable to the CBHI scheme.
The premium structures were based on
the household’s Ubudehe category (as the
proxy for ability to pay). As a result of this
MoH and MINALOC-led process, there
now exist Ubudehe databases maintained
by the local administration officials
in each sector, keeping track of the
socioeconomic status of every household
in Rwanda and their relevant Ubudehe
categories. Having a better estimate of
the total population in the informal
Source: Social Stratification Database, 2011
61
Conclusion
Using evidence from a decentralized,
village-level wealth ranking system or
Ubudehe has ensured the principles of
cross-subsidies from the wealthier to the
less wealthy within the national CBHI
scheme. In particular, re-organizing the
CBHI categories according to these criteria
now allows for a more robust examination
of income-related inequalities, particularly
related to equity in utilization of health
services and financial protection across
CBHI categories. Forthcoming studies
conducted through several partners will
discuss the implications of this Ubudehebased categorization of CBHI premiums,
and will provide recommendations on
how to ensure the financial sustainability
of the CBHI scheme. The mutuelles have
now moved under the Rwanda Social
Security Board with the aim of ensuring
better management, and to ensure a
split in the provider-purchaser role of
the MoH to ensure accountability and
transparency, as well as a cross-subsidy
between the formal and informal sectors.
As a result, there is further potential for
the Ubudehe-based CBHI categories to
provide improved evidence in targeting a
greater share of the “needy” population. p
sector has myriad impacts on the financial
sustainability of the CBHI scheme,
particularly one that is driven through
a prepayment premium mechanism as
in Rwanda. Further, validations of the
data have allowed administrators to
corroborate categories of individuals with
the information available in databases, and
local sections and cells can easily access
these data through an integrated HMIS
system. Needless to say, this process has
various implications for the financial
sustainability of CBHI sections, as well
as improved governance for sectors.
The categorization according to the
Ubudehe system has thus allowed for an
equitable redistribution that considers
individual capacity to pay. In particular,
Rwandans with fewest assets (amounting
to 25% of the overall population, or
those in CBHI Category 1) are easily
identified, as premiums for this group are
paid by the government and development
partners. These beneficiaries are not
supposed to pay the health centre fee
or the hospital co-payments. CBHI
62
beneficiaries in other categories also pay
a small fixed fee at health centres (which
goes towards CBHI administration costs),
and contribute a co-payment of 10% of
the total CBHI bill to the district and
referral hospitals. These individuals are
obligated to pay the annual premium and
this is primarily enforced through peer
sensitization and pressure using ibimina
– groups of several households led by
one inhabitant. They typically collect
and deliver premiums to cooperatives or
bank accounts on behalf of members.
This avoids long queues at the point
of payment, and the peer pressure is
constructive in reminding members of
the benefits of mutuelles and the need to
pay premiums. In the past, enforcement
has been based on requiring a mutuelle
membership card when accessing other
government services, such as a passport.
A final enforcement mechanism is that
coverage of members has been part of
mayors’ performance-based contracts
with the President of Rwanda, whereby
mayors have promised to achieve
universal coverage for mutuelles.
References
1. Rwiyereka AK et al. Situational Analysis and Feasibility
Study of Options for Harmonization of Social Health
Protection Schemes Towards Universal Health Coverage
in the East African Community Partner States. East African
Community August 2014.
2. World Bank. Rwanda Country Status Report. Ministry of
Health, Rwanda 2009.
3. GoR. Rwanda Demographic and Health Survey. Ministry of
Health, Rwanda and Measure DHS 2010.
4. GoR. Rwanda Community Based Health Insurance Policy.
Ministry of Health, Government of Rwanda April 2010.
5. Ubudehe is a process at the village-level for community
decision making. Ubudehe incorporates a “povertymapping” process, which has a systematic methodology
and allocates each household to one of six ordinal income
and poverty-related categories differentiated by welldefined qualitative criteria.
6. Niringiye A, Ayebale C. Impact Evaluation of the
Ubudehe Programme in Rwanda: An Examination of the
Sustainability of the Ubudehe Programme. J Sus Dev Afr
2012; (14)3.
7. GoR. Annual Report: Community-Based Health Insurance.
Ministry of Health, Government of Rwanda October 2012.
8. Lu C et al. Towards Universal Health Coverage: An
Evaluation of Rwanda Mutuelles in its First Eight Years.
PLoS ONE 2012; 7(6): e39282. doi:10.1371/journal.
pone.0039282.
9. Integrated Health Systems Strengthening Project (IHSSP)
and USAID/Rwanda database on social stratification
project. Final report and next steps. Report submitted to
Ministry of Health and Ministry of Local Government,
Rwanda June 2011.
B
L’impact des modalités
d’allocation des ressources
dans les mécanismes
d’exemption sur l’équité :
Plan Sésame, Sénégal
Maymouna Ba,i Fahdi Dkhimi,ii Alfred Ndiayei
Auteur correspondant : Maymouna Ba, e-mail : [email protected]
A
RÉSUMÉ—La plupart des politiques d’exemption
en Afrique subsaharienne se dotent de facto de
modalités dites passives d’allocation de ressources.
Le Plan Sésame – mécanisme d’exemption adopté
au Sénégal en 2006 et ciblant les citoyens âgés de
60 ans et plus – n’échappe pas à la règle : il se base
sur le paiement à l’acte comme modalité d’achat
de services. Ce texte a pour but d’explorer l’effet
de cette modalité passive d’achat de services sur
l’équité d’accès aux soins du Plan Sésame. Notre
analyse se base sur une enquête menée au Sénégal
entre mai 2012 et juillet 2013. Une méthodologie
mixte incluant une revue de documents de
politiques, une analyse des détenteurs d’enjeux et
une enquête-ménage a été utilisée. Les résultats
montrent que le Plan Sésame est caractérisé par
un financement hybride, lequel a favorisé les
personnes âgées évoluant dans le secteur formel
qui ont un meilleur accès aux hôpitaux. Ceux-ci ont
donc capté une grande partie des budgets alloués
au Plan Sésame. En somme, les couches sociales les
plus aisées et celles résidant en milieu urbain ont
plus de chance d’accéder aux ressources du Plan
Sésame.
See page 72 for the summary in English.
u début des années 2000, de
plus en plus de pays à faibles ou
moyens revenus se sont engagés
dans des réformes de financement de
la santé orientées vers des mécanismes
de subventions ou d’exemption des
paiements.1,2,3 Ceux-ci ont ciblé certaines
catégories dites vulnérables (femmes,
enfants, personnes âgées, etc.) ou ont
porté sur certains types de soins en raison
de leur coût exorbitant (césarienne).
Ces réformes sont sous-tendues par un
paradigme d’équité développé au niveau
international, paradigme découlant des
barrières financières qui ont beaucoup
réduit les recours aux soins pour
les pauvres.2
Cependant, si de telles réformes ont
entrainé une plus grande utilisation
des services de santé, 4 elles n’ont
paradoxalement pas eu un impact
significatif sur l’accès aux soins pour les
personnes pauvres. En effet, ces mesures
peinent encore à réduire les inégalités
économiques en termes d’accès aux soins.3
En somme, il existe d’autres facteurs liés
à l’environnement social ou institutionnel
de ces mécanismes et qui concourent à
limiter leur portée, en désavantageant les
populations qui en ont le plus besoin.
La question du financement, notamment
son insuffisance, est souvent présentée
comme un élément déterminant des
faibles performances de ces politiques
d’exemption. 3,5 Le succès limité de
ces mécanismes peut trouver aussi
son explication dans les modalités de
financement adoptées, dont l’impact réel
est encore peu exploré. Cet article compte
combler cette lacune. À partir d’une étude
sur le Plan Sésame, mécanisme de gratuité
des soins pour les personnes âgées mis en
œuvre au Sénégal en 2006, il met le focus
sur les formes d’allocations des ressources
et ses effets sur l’accès équitable aux
services proposés.
Méthodologie
Les résultats présentés ici s’appuient sur
une analyse de documents (politiques
nationales, documents de procédures,
rapports d’évaluation, documents légaux :
arrêtés, décrets, notes circulaires). Cette
analyse de documents a été suivie d’une
enquête qui a été conduite entre mars
2012 et juillet 2013. Des entretiens ont
été menés auprès de 54 acteurs de la santé
de profils divers : décideurs, prestataires
de soins, leaders d’associations et
représentants d’organismes internationaux
… Une enquête-ménage a été effectuée
dans quatre sites sélectionnés de manière
raisonnée. Ils correspondant à des régions
administratives (Dakar, Diourbel, Matam
et Tambacounda) et incluent des zones
urbaines et rurales. L’échantillon, de type
aléatoire proportionnel, est constitué de
2 933 ménages comprenant chacun au
moins une personne âgée. Cet effectif est
réparti proportionnellement à l’effectif
des personnes âgées résidant dans
chaque site.
Le traitement des données d’entretien
a été fait avec le logiciel NVivo suivant
la méthode de codage déductif. Les
données quantitatives ont été analysées
avec le logiciel SPSS (analyse régressive).
Le recours à cet ensemble de méthodes
mixtes nous a permis de retracer les
flux financiers, puis d’analyser, à partir
des discours des détenteurs d’enjeux,
les raisons liées au choix du mode de
financement, et enfin, d’évaluer l’équité
i Centre de recherche sur les politiques sociales, Dakar, Sénégal
ii Institut de Médecine Tropicale, Anvers, Belgique
63
dans la couverture d’accès aux services
du Plan Sésame.
Résultats
Le Plan Sésame a pour objectif d’assurer
l’accès à des soins gratuits pour tous
les sénégalais âgés de 60 ans et plus qui
représentent 5,2 % de la population
totale (Agence National de Statistique
et de la Démographie, 2011). Les
catégories dépourvues de couverture
sociale formelle, qui représentent 70 %
des personnes âgées, représentent la
cible principale de cette politique. Le
mécanisme concerne aussi celles qui
disposent déjà de protection sociale
de santé, notamment les retraités du
secteur formel, organisés sous la tutelle
de l’Institut de Prévoyance Retraite du
Sénégal (IPRES – l’organisme qui gère
les retraités issus du secteur privé) et
du Fonds de Retraite (FNR – fonds qui
gère le système de couverture sociale
des fonctionnaires et qui est financé par
le budget de l’État et octroie une prise
en charge s’élevant à 80 % des frais de
consultation et d’hospitalisation) pour
lesquels il vient en complément de la partie
non couverte. Le Plan Sésame concernent
la plupart des prestations offertes dans les
services publics de santé et incluent tous
les niveaux de soins : postes de santé,
centres de santé et hôpitaux.6,7
Les contours d’un mécanisme
de financement passif
Les fonds du Plan Sésame sont alloués
sous forme d’avance budgétaire aux
hôpitaux nationaux et régionaux d’une
part, et de dotation de médicaments pour
les centres et postes de santé d’autre part.
Ces deux modes de financement sont
justifiés par le fait que ces structures
de santé ont des statuts différents. En
effet, la réforme hospitalière introduite
en 1998 a érigé les hôpitaux nationaux et
régionaux en Établissement Publics de
Santé (EPS) et leur a conféré en même
temps une certaine autonomie dans la
gestion de leur budget. 8 L’obligation
d’autofinancement, qui découle de
ce statut d’autonomie, les a placés
dans une position qui leur permet de
négocier les modalités d’allocation de
tout financement venant de l’extérieur.
Ce qui n’est pas le cas des centres et
postes de santé qui, ne disposant pas
64
d’une telle personnalité juridique, restent
entièrement des « services de l’État » :
« Pour les districts, l’État était
tout à fait à l’aise, ce sont des
services administratifs. Donc, le
remboursement en nature était une
option assez confortable pour l’État.
Là, il n’y a pas de problème, il n’y
avait pas de négociations…. Par
contre, pour les EPS, ce sont des
structures autonomes. Ce sont des
services qu’elles facturent et donc les
soins ne sont pas gratuits », déclare
un acteur du Ministère de la santé.
Il faut cependant souligner que le
préfinancement aux hôpitaux n’a été
effectif qu’au démarrage. En effet, les fonds
initialement pourvus se sont vite épuisés,
aucun financement dédié n’ayant été prévu
pour assurer la régularité des allocations.7
L’analyse du corpus de données établit
que dans les faits, après la première année,
les hôpitaux ne fonctionnaient plus sur
préfinancement mais plutôt sur un système
de recouvrement.
L’allocation des ressources du Plan
Sésame, devenue donc passive en cours
de mise en œuvre et entachée par une
irrégularité des paiements, a finalement
induit l’accumulation d’une dette de
l’État envers les établissements publics
de santé. En 2009, cette dette était estimée
à 4 milliards de francs CFA.9 Dès lors,
du fait des difficultés de recouvrement
des prestations effectuées, la plupart des
structures de santé appliquaient le Plan
Sésame de manière aléatoire :
« On n’a plus les moyens de suivre
cette demande-là. […] On continue à
prendre selon nos possibilités, mais si
une personne âgée vient ici et qu’on
n’a pas d’intrants pour la prendre
en charge, on ne la prendra pas en
charge », nous confie un Directeur
d’hôpital en milieu rural.
Ce problème de financement découle
en grande partie du peu de préparation
dont a fait l’objet ce mécanisme (absence
d’étude de faisabilité, de stratégie claire
de financement, d’expérience pilote...).
Beaucoup d’acteurs interrogés pensent
d’ailleurs que la mise en place du Plan
Sésame a été quelque peu précipitée,
du fait de contraintes liées à la décision
politique. Le démarrage rapide, à un
an d’une élection présidentielle, laissait
penser que des motivations politiques
étaient sous-jacentes.
L’insuffisance du financement,
caractérisée par un achat de services passif,
est donc présentée comme à l’origine
des nombreux dysfonctionnements
intervenus au cours de l’application.
Néanmoins, en partant de l’analyse des
flux financiers opérés durant les trois
premières années de mise en œuvre
de ce mécanisme (2006–2009), nous
remarquons qu’en plus de l’irrégularité
du financement, la modalité d’allocation
a été aussi un élément déterminant dans
l’introduction des différences d’accès.
Un financement hybride ou
l’introduction d’iniquités
sociales
Les fonds du Plan Sésame proviennent de
deux sources : l’État et l’IPRES. La part
de l’État est dévolue aux fonctionnaires
retraités du secteur public et aux personnes
âgées dépourvues de couverture formelle.
Quant à la contribution de l’IPRES
(qui représentait 30 % du fonds initial
– le fonds de démarrage s’élevait à
1 milliard), elle est dévolue à ses propres
pensionnaires (tous issus du secteur privé)
et directement versée aux hôpitaux.
Ce système de financement, qui ne repose
pas sur une mutualisation des fonds, pose
dès le départ un problème d’harmonisation
de la gestion financière du Plan Sésame. En
effet, il s’avère que l’IPRES a continué à
fonctionner sur la base de préfinancements
plus ou moins réguliers aux hôpitaux,
au moment où les fonds provenant de
l’État n’étaient plus alloués de manière
systématique. En plus, la Pharmacie
Nationale d’Approvisionnement (PNA),
qui n’arrivait plus à rentrer dans ses fonds,
avait arrêté d’approvisionner les districts
en médicaments.
On assiste ainsi à une dualité dans la
gestion financière, avec toutefois une
gestion moins tatillonne pour l’IPRES.
Ce dernier a passé une convention de
préfinancement avec les hôpitaux et a
mis en place un manuel de procédures
opérationnelles. Il a dédié au Plan Sésame
un budget basé sur une estimation des
coûts. Quant au ministère, il n’avait même
pas une unité de gestion fonctionnelle.
Ainsi, l’IPRES a obtenu de meilleurs
résultats dans la prise en charge de ses
membres au sein des structures de santé.
Dans l’esprit de beaucoup d’acteurs, il
existait deux « Plan Sésame » : « un Plan
Sésame État » qui fonctionnait de manière
aléatoire sur la base d’un paiement à l’acte
et un « Plan Sésame IPRES » basé sur
des conventions de préfinancement aux
hôpitaux. Cette dualité dans le financement
avait une conséquence manifeste : d’un
côté, une bonne partie des personnes
âgées étaient éconduites des structures
de santé qui attendaient des ressources
publiques, de l’autre, des membres de
l’IPRES continuaient à recevoir des soins
exemptés dans les mêmes structures, au
titre du Plan Sésame. Cet accès inégal pour
les personnes âgées aux soins de santé est
bien exprimé par un acteur :
« Ceux qui sont affiliés à l’IPRES
sont correctement pris en charge car il
y a le recouvrement. Ils sont recouvrés
même par anticipation. Il y a même
un acompte versé aux hôpitaux par
l’IPRES. Le problème concerne les
autres personnes. »
Ce financement à deux vitesses a donc
introduit des différences de traitement
au profit des retraités de l’IPRES. La
modalité d’achat de services a donc
grandement favorisé une catégorie qui
n’était pas la cible première de cette
politique de gratuité.
Un secteur primaire
largement désavantagé
L’analyse de documents montre que
le niveau primaire a effectué moins
de prestations et donc reçu peu de
financement. En effet, de 2006 à 2009, le
niveau primaire (district) a absorbé moins
de 10 % des dépenses effectuées dans
le cadre du Plan Sésame, contrairement
aux EPS du niveau secondaire (hôpitaux
régionaux) et tertiaire (hôpitaux
nationaux). En effet, cela est dû, en partie,
au fait que les centres et postes de santé
subissent de plein fouet les contrecoups
de l’irrégularité des remboursements en
nature. Contrairement aux hôpitaux qui
jouissent d’une autonomie financière
plus importante, les structures du
niveau primaire supportent moins les
retards dans l’approvisionnement des
médicaments.
Figure 1. Allocations et dépenses du Plan Sésame par niveau de soins entre
2006 et 2009
Budget allocation
Par niveau des soins
Montant dépenses
Par niveau des soins
Primaire
Secondaire
Tertiaire
Primaire
Secondaire
Tertiaire
48 %
53 %
43 %
43 %
4%
9%
NATIONAL
NATIONAL
Source : Tableau constitué à partir des données du rapport de l’Inspection générale des Finances, Rapport 2011
Les postes de santé, qui se trouvent au
niveau inférieur de la pyramide, ont été
les plus lésés par ce mode d’allocation des
ressources. Ils n’ont pas eu les capacités
d’appliquer le Plan Sésame sans une
garantie d’un recouvrement adéquat des
coûts et n’ont pas voulu se substituer aux
défaillances de l’État, comme l’explique
si bien cet infirmière chef de poste (ICP)
milieu rural :
« Je n’ai jamais appliqué le Plan
Sésame au niveau du poste […]
J’ai avec moi les papiers pour les
références mais quand ils viennent
en consultation, je ne vais pas leur
donner gratuitement les médicaments.
Ça, je ne le fais pas. »
Ce fait est d’autant plus contradictoire que
le Plan Sésame promeut le référencement
et que l’enquête-ménage a montré que
le poste de santé demeurait le service de
santé le plus fréquenté par les personnes
âgées (notamment en milieu rural où
il concerne 45,4 % des fréquentations,
contre 20,3 % des recours en milieu
urbain). Finalement, ce sont les personnes
ayant un accès plus facile aux hôpitaux
qui ont le plus bénéficié et le plus utilisé le
Plan Sésame. Cette catégorie de personnes
âgées correspond plus à celle évoluant
dans le secteur informel et résidant en
milieu urbain. Finalement, l’essentiel des
prestations a été fourni par les hôpitaux qui
ont capté la plupart des ressources allouées
au titre du Plan Sésame. Quant aux postes
de santé, ils n’ont pas réussi à mettre en
œuvre normalement le Plan Sésame.
Quand le mécanisme d’achat
de services engage un
processus d’exclusion
Le manque de mutualisation des
fonds, associé à une allocation passive
induisant de facto un hôpital centrisme,
a, dès le départ, constitué le socle de
l’exclusion d’une certaine catégorie de
personnes âgées. Cela a bien entendu
des conséquences sur les résultats
obtenus par le Plan Sésame. L’enquêteménage montre que ce sont finalement
les personnes âgées résidant en milieu
urbain et les retraités du secteur formel
qui ont le plus bénéficié du Plan. Aussi,
le quartile de population le plus aisé a une
probabilité significativement plus élevée
d’accéder aux ressources du Plan Sésame
que le quartile le plus pauvre.
Finalement, le mode de financement
du Plan Sésame, choisit d’abord pour la
« souplesse » qu’il présente, a peu tenu
compte des principes d’équité. En termes
d’allocations des ressources, les inégalités
de niveau de soins qui en découlent
ont induit des différences d’accès, au
détriment des personnes âgées n’ayant
pas un accès facile aux hôpitaux, celles
vivant en zone rurale notamment.
Discussion
Des études menées sur d’autres
programmes de gratuité montrent que le
fonctionnement des mécanismes portent
en germes les éléments de leurs faibles
65
Tableau 1. Déterminants de l’accès aux services de santé et de l’exemption au
Plan Sésame
Variables
Odds ratio
Erreur standard
Interval de
confiance
Informé – Plan Sésame
1,500
(0,156)***
1,223
1,839
Chef de ménage
1,204
(0,148)
0,946
1,533
Homme
0,939
(0,109)
0,748
1,180
Wolof
1,058
(0,108)
0,866
1,291
Éducation
0,978
(0,123
0,765
1,250
Urbain
0,979
(0,122)
0,767
1,250
Respect
1,169
(0,126)
0,946
1,445
Participation religion
1,066
(0,113)
0,866
1,313
Visites – amis/parents
0,834
(0,084)*
0,685
1,017
Pas seul
1,124
(0,114)
0,921
1,373
Vote
0,875
(0,095)
0,707
1,053
Utilise media
0,864
(0,087)
0,709
1,053
Satisfait gouvernement
1,007
(0,117)
0,802
1,264
Membre parti politique
1,229
(0,193)
0,904
1,671
Carte pension
1,590
(0,215)***
1,220
2,072
Activité professionnelle
0,842
(0,099)
0,669
1,060
Secteur formel
1,031
(0,228
0,669
1,589
Revenus réguliers
1,033
(0,107)
0,843
1,266
Ressources écon – q2
0,805
(0,124)
0,596
1,089
1,310
(0,201)*
0,969
1,771
1,702
(0,271)***
1,246
2,325
1,358
(0,227)*
0,978
1,886
Observations
1,682
Degré d’importance ES en parenthèses: *** p<0,01, ** p<0,05, * p<0,1
performances.3,10 Plus particulièrement,
le sous-financement de ces mécanismes
est souvent présenté comme une menace
à leur pérennité11 et justifie le fait que
beaucoup d’auteurs préconisent la
disponibilité de ressources suffisantes et
durables comme un préalable à la mise en
place de ces programmes.1
Notre analyse montre aussi l’importance
des modalités d’allocation des ressources
pour la viabilité de ces mécanismes.
L’aspect lié à la mutualisation des fonds,
par exemple, semble déterminant dans
l’efficacité de la gestion financière. En
effet, la mise en commun des fonds,
qui fait défaut dans le cadre du Plan
Sésame a introduit des inégalités d’accès
au détriment des catégories issues de
l’informel, cibles première du Plan.
L’efficacité d’un pooling des fonds a fait
ses preuves dans d’autres contextes où la
mise en synergie de différentes sources
de financement a conduit à de meilleurs
résultats.13,14
Tout cela met en évidence l’effectivité de
la formulation et de la mise en œuvre des
mécanismes d’exemption, où la notion
d’équité est peu intégrée. Cela remet en
question le contexte de mise en place de
66
ces programmes qui, souvent, dépend
de pressions externes et est aussi le
fruit d’opportunités politiques internes.5
L’empressement qui accompagne
l’application de ces décisions officielles ne
favorise pas de mures réflexions et rend
complexe leur opérationnalisation.14,15
Le Plan Sésame, par une absence de
stratégies claires en ce qui concerne le
mode de financement, a ainsi enclenché
des processus d’iniquités dès sa phase
de design. Les modalités d’allocation
des ressources, non basées sur le
principe d’équité, font que de nombreux
bénéficiaires potentiels (en particulier les
plus pauvres) se trouvent exclus de ce
programme dès son entame.
Conclusion
Dans le cadre du Plan Sésame, la
modalité passive d’achat de services
génère une dissymétrie dans l’allocation
de ressources, au détriment des régions
rurales et des soins primaires de santé.
Cette dissymétrie explique en partie la
distribution significativement inéquitable
des ressources allouées au Plan Sésame au
profit des groupes les plus aisés. L’achat
passif de services semble exacerber les
inégalités d’accès aux soins et entraver le
processus de décentralisation sanitaire.
Cet exemple montre l’importance de
discuter de la question de l’équité dans
les modalités d’achat de services dès
la phase de design d’une politique de
financement. p
Remerciements
Les résultats présentés ici découlent d’une recherche financée
par la Commission Européenne dans le cadre de son 7ème
programme-cadre (FP7/2007 – Agrément No. 261440). Les
opinions et conclusions présentées dans cet article sont
de la seule responsabilité des auteurs et ne reflètent pas
nécessairement le point de vue de la Commission.
Références
1. Gilson L, McIntyre D. Removing user fees for primary
care in Africa: The need for careful action. BMJ 2005;
331:762–765.
2. OMS. Le financement des systèmes de santé : le chemin vers
une couverture universelle. Rapport sur la santé dans le
monde. Genève : Organisation Mondiale de la Santé 2010.
3. Ridde V, Queille L, Kafando Y. Capitalisations de politiques
publiques d’exemption du paiement des soins en Afrique de
l’Ouest. Université de Montréal : CHUM 2012.
4. Heinmüller R, Dembélé YA, Jouquet G, Haddad S, Ridde V.
Free healthcare provision with an NGO or by the Malian
Government. Field Actions Science Reports 2012 (special
issue 8).
5. De Sardan J-P O, Ridde V. L’exemption de paiement des
soins au Burkina Faso, Mali et Niger : Les contradictions
des politiques publiques. Afrique contemporaine 2012;
243:11–32.
6. République du Sénégal. Rapport sur le Plan Sésame de
soins gratuits pour les personnes âgées de 60 ans et plus au
Sénégal : revue 2008. 2009.
7. Ministère de la Santé. Évaluation des initiatives de
subventions et du fonds social. 2007.
8. Ministère de la Santé. La réforme hospitalière : Présentation
et décrets. 1998.
9. Ministère de l’Économie et des Finances. Rapport n°2-11/
IGF du 31 mars 2009 portant sur la vérification de l’encours
des dettes dues aux formations sanitaires dans le cadre du
Plan Sésame. 2009.
10. Leye MMM, Diongue M, Faye A. Analyse du
fonctionnement du plan de prise en charge gratuite
des soins chez les personnes âgées « Plan Sésame » au
Sénégal. Santé Publique 2013; 25:101–106.
11. Witter S, Dieng T, Mbengue D, Moreira I, Brouwere VD. The
national free delivery and caesarean policy in Senegal:
Evaluating process and outcomes. Health Policy Plan 2010;
25(5):384–92.
12. Moreno-Serra R, Smith PC. Does progress towards
universal health coverage improve population health? The
Lancet 2012; 380:917–23.
13. Savedoff W D, De Ferranti D, Smith A L, Fan V. Political and
economic aspects of the transition to universal health
coverage. The Lancet 2012; 380:924–32.
14. Ridde V, Morestin F. A scoping review of the literature on
the abolition of user fees in health care services in Africa.
Health Policy Plan 2010; 26:1–11.
15. Mbaye EM, Ridde V, Kâ O. « Les bonnes intentions ne
suffisent pas » : analyse d’une politique de santé pour
les personnes âgées au Sénégal. Santé Publique 2013;
25:107–112.
News and events
Renowned public health experts and leaders endorse a vision for an Africa health
transformation programme to enhance health in the African Region
An independent advisory group (IAG),
comprising renowned public health experts
and leaders, has endorsed the Africa Health
Transformation Programme 2015–2020:
A vision for universal health coverage,
proposed by Dr Moeti, WHO Regional
Director for Africa.
“We are taking a once-in-a-generation
opportunity to transform the future for
Africa, to strengthen health and economic
security globally, and to deliver on the goals
for a new era of sustainable development”,
said Dr Moeti.
At its inaugural meeting, held in
Johannesburg 4–5 May 2015, the IAG
congratulated the Regional Director for
convening the IAG and for her vision, calling
it a step in the right direction and a testimony
to her personal commitment to change the
work of WHO in the Region.
In her opening remarks, Dr Moeti observed
that addressing the health challenges in
the African Region required rethinking the
way the WHO Secretariat approaches the
planning and implementation of health
programmes and services in support of
Member States. It is expected that the
implementation of the transformation
programme will address the unacceptable
inequities and injustices in the Region’s
health development.
The WHO Regional Office for Africa will lead
the transformation in health and well-being
based on five interrelated and overlapping
priorities:
• Improving health security;
• Strengthening national health systems;
• Sustaining focus on health-related SDGs;
•Addressing the social determinants of
health; and
• Transforming the WHO Regional Office
for Africa into a responsive and resultsdriven organization.
The Regional Director told the participants
that the strategy is bold and ambitious, but
that it can be delivered. “We will deliver
on our promise through our shared values
of equity, dignity, transparency, integrity,
professionalism and openness”, she added.
It was highlighted that the growing
recognition of health as critical to the SDGs,
the dividends of unprecedented economic
growth, political stability and the birth of a
new middle class, among other factors,
could be translated into tangible human
development benefits that can enable Africa
to contribute to global health and economic
security worldwide.
The IAG was set up by Dr Matshidiso Moeti
to provide strategic and policy advice aimed
at strengthening the work of WHO in the
African Region to make better health a
reality for people.
WHO and AUC take stock on joint efforts to improve collaboration
High-ranking officials from the African
Union Commission (AUC) and WHO met
in Brazzaville on 30 June to review their
collaborative efforts to improve the health of
people in Africa.
Among the issues discussed were the
progress made so far in the WHO-AUC
partnership; the establishment of the African
Centre for Disease Control (African CDC) and
ways of improving collaboration between it
and WHO. The meeting also deliberated on
how far African countries have implemented
the agreed actions during the first AUCWHO ministerial conference held in Luanda,
Angola in April 2014.
Welcoming the delegates, Dr Matshidiso
Moeti, the WHO Regional Director for
Africa, underscored the strategic importance
of the WHO-AUC partnership. She noted
that the comparative advantage of the
two organizations, their convening powers
and their roles as secretariats of Member
States can help position health as a central
development theme on the continent,
particularly in the context of the post-2015
development agenda.
“It is particularly important that we continue
to explore how best we can more effectively
synergize the work of our two institutions
for the betterment of our people in Africa.
I am talking about the political mandate of
the AUC and the technical mandate of WHO
and how best they can be used together in
a complementary and synergistic manner”,
said Dr Moeti.
The Regional Director commended the AUC
for its advocacy and mobilization of nearly
1 000 volunteers in response to the Ebola
virus disease outbreak.
In his remarks, Dr Mustapha Kaloko, the
AUC Commissioner for Social Affairs,
highlighted some of the achievements of
the AUC-WHO partnership during the past
three years, including the re-establishment
of a WHO Liaison Office to the AUC, a
joint ministerial meeting in Angola and the
development of a joint work plan. He said
although the collaboration is going well,
both parties could further strengthen it by
having a common position before consulting
Member States on matters of mutual
interest such as the establishment of the
African CDC. Dr Kaloko further stressed
the need for the AUC and WHO to work
together to respond to emergencies as well
as to coordinate the continent in speaking
with one voice at international fora such as
the World Health Assembly.
The two-day bilateral meeting agreed on a
revised joint work plan for the period 2015–
2016, including preparations for the next
joint ministerial meeting which is expected
to take place in Tunis, Tunisia in April 2016.
67
African public health leaders unite to end preventable deaths and improve the health of
women, children and adolescents by 2030
Hundreds of leaders and public health
experts from across Africa gathered,
6–7 May, to identify game-changing
interventions to accelerate progress towards
improving the lives of millions of women,
children and adolescents. This consultation
provided a roadmap – an updated Global
Strategy for Women’s, Children’s and
Adolescents’ Health – to end preventable
deaths of women, newborns, children and
adolescents by 2030, which will be launched
alongside the new SDGs in September.
This revised strategy builds on the Global
Strategy for Women’s and Children’s Health,
launched in 2010 by the United Nations
Secretary-General.
“Over the last two decades, the world has
made unprecedented progress in advancing
women’s and children’s health. In 2013, 6.4
million fewer children died than in 1990, and
in this same timeframe, deaths of women
during pregnancy and childbirth were cut by
almost half”, said Graça Machel, Chair of the
Partnership for Maternal, Newborn and Child
Health (PMNCH). “African leaders have been at
the forefront of these efforts, as demonstrated
by the Campaign on Accelerated Reduction
of Maternal, Newborn and Child Mortality in
Africa and the many commitments made to
the original global strategy.”
Despite immense progress, the scale of
the problem remains vast. As of 2013,
17 000 children under the age of five still
die every day. Moreover, approximately
225 million women who want to prevent
or delay pregnancy are not using modern
contraceptives and each hour, 33 women
die from preventable causes related to
pregnancy and childbirth. Over half of
maternal deaths occur in sub-Saharan Africa
alone. To reach the global goals for women’s
and children’s health by 2030, it is estimated
that an additional US$ 5.24 is needed
per person per year. Calls for increased
funding stress the need for investments to
be predictable and sustainable, as well as
increasingly efficient.
“Healthy women and children are the
bedrock of stable, productive societies”, said
Dr Aaron Motsoaledi, Minister of Health of
the Republic of South Africa. “Ensuring the
health of every woman, child and adolescent
will only become more urgent as the next
generation grows. We are already grappling
with the largest population of young people
in history, and it is projected that in 35 years,
Africa will be home to over a third of the
world’s youth. Imagine if all of these young
women and men could lead healthy lives
and raise healthier families.”
This meeting – co-hosted by the South
African National Department of Health and
the United Nations Secretary-General’s
Every Woman Every Child movement, with
support from PMNCH and WHO – is part of
a broad consultative process to update the
original global strategy. It will focus on new
and targeted solutions to address societal
and structural barriers to health, such as
education, legal entitlements for women and
children, and nutrition. Given demographic
shifts in Africa, the consultation will have a
large youth component.
First joint World Bank and WHO training course on universal health coverage for
francophone countries
Universal health coverage is at the centre of
health system reform efforts of many lowand middle-income countries. There has been
much demand for UHC and health financing
training courses, and both the World Bank
and the World Health Organization have
been providing training events in English.
There is equally strong demand in numerous
francophone countries. In response, the
World Bank and World Health Organization
have jointly organized their first WB-WHO
course on UHC for francophone countries.
The course objectives were to enhance
country knowledge, skills and technical
capacities as well as to support francophone
counterparts in their UHC reform process.
The course took place in Dakar, Senegal,
from 20–25 April. It attracted 113 participants
and 16 country teams (Benin, Burkina Faso,
Cameroon, Central Africa Republic, Chad,
Congo, Côte d’Ivoire, Djibouti, Democratic
Republic of the Congo, Guinea, Haiti,
Madagascar, Mali, Mauritania, Niger and
Senegal). Each country team consisted of six
to eight members, and included high-level
representatives from ministries of health,
finance, labour, planning and/or social affairs
and health insurance agencies. World Bank
task team leaders and WHO country health
systems officers also participated. Two guest
speakers from Burundi and Gabon joined to
68
share their experiences, as well as observers
from the Agence Française de Développement,
German BACKUP Initiative and Japan
International Cooperation Association who
also provided financial support for the course,
which is gratefully acknowledged.
The five-day course consisted the following
sessions: an overview of the World Bank’s
flagship approach to UHC; definition and
objectives of UHC; the health financing
situation in francophone countries; revenue
collection; fiscal space; pooling; coverage
of the informal sector; strategic purchasing;
provider payment mechanisms; resultsbased financing; benefit package design;
governance; human resources; monitoring
UHC progress; and access to drugs.
Theme focused group work on communitybased health insurance, social health
insurance and “free health-care policies”
allowed for further in-depth discussion.
These sessions were complemented by
group work within country teams to further
reflect on individual country health financing
strategies and outline proposals for health
financing policy reforms to promote in their
own country setting.
The course was highly appreciated with
participants valuing the opportunity for
learning and sharing experiences from across
francophone countries. The Minister of Health
from Madagascar, Professor Andriamanarivo,
reported, “the course was extremely
helpful and timely for Madagascar as we are
initiating the formulation of a health financing
strategy this month”. Dr Sossou, Deputy
General Secretary of the Ministry of Health
from Benin, stated, “beyond theoretical
knowledge, the training course was an
opportunity to leverage other countries’
experiences. Capitalizing is essential for
Benin as we move on adjusting our health
financing strategy before it gets approved by
the Council of Ministers later this year”.
Moreover, the joint organization of the
course sends out a powerful message with
respect to a harmonized approach towards
UHC by both the World Bank and WHO.
The course has been a valuable experience
and there is strong interest both among
country participants as well as partners
to continue and repeat this type of event.
Both organizations are engaged to continue
to collaborate by supporting countries in
capacity building, evaluating the progress
of the implementation of UHC, facilitating
innovation and learning-by-doing at country
level and sharing and disseminating best
practices. The World Bank and WHO will try
to expand such joint initiatives.
Abstracts
RÉSUMÉS EN VERSION FRANÇAISE
SUMÁRIOS EM VERSÃO PORTUGUESE
The critical role of health nancing
in progressing universal health
coverage. . . . . . . . . . . . . . . . . . . 3
1
Le rôle crucial du financement de la santé dans les
progrès vers la couverture sanitaire universelle
RÉSUMÉ—D’immenses progrès ont été accomplis
au cours des quatre dernières décennies en matière
de développement de la vaccination dans la Région
africaine. Associée à d’autres interventions de soins de
santé primaires et de développement, la vaccination a
eu un impact notable sur la réduction de la mortalité
annuelle des enfants de moins de cinq ans. Cependant,
selon des estimations, quatre pays de la Région africaine
(Afrique du Sud, Éthiopie, Nigéria et République
démocratique du Congo) abritent 22 % (soit 4,3 millions)
des nourrissons non vaccinés dans le monde. Des défis
restent à relever pour vacciner tous les enfants de la
Région, et atteindre les quelque 20-30 % d’enfants
qui échappent encore à la vaccination. En plus des
vaccins disponibles de longue date (antidiphtériqueantitétanique-anticoquelucheux, antirougeoleux,
antipoliomyélitique et antituberculeux), des vaccins plus
récents, tels que le vaccin anti-hépatite B, sont introduits
dans la Région, mais leur utilisation et leur diffusion
sont lentes et inégales au sein, et entre, des pays. Le
nouveau plan stratégique régional pour la vaccination
2014-2020 vise à fournir des orientations politiques et
programmatiques aux États Membres, conformément au
Plan d’action mondial pour les vaccins 2011–2020, afin
d’optimiser les services de vaccination et d’aider les pays
à renforcer leurs programmes de vaccination.
O papel fundamental do financiamento da saúde
para fazer avançar a cobertura universal de saúde
SUMÁRIO—É evidente que o financiamento da saúde
é crucial para providenciar os diferentes componentes
dos sistemas de saúde que são essenciais para se
progredir na implementação da cobertura universal de
saúde (CUS). No entanto, existem várias condicionantes
dos sistemas de financiamento da saúde em toda
a Região Africana que estão a impedir progressão,
nomeadamente: recursos financeiros insuficientes;
grande dependência na despesa de saúde resultante
de pagamentos directos; gestão ineficaz dos sistemas
de saúde; níveis insatisfatórios de governação e
responsabilização; falta de aproveitamento das
contribuições das partes interessadas no financiamento
da saúde; pouca investigação, monitorização e avaliação.
Fizeram-se progressos no que toca ao último problema
mencionado, com a introdução do Sistema Revisto de
Contas de Saúde de 2011. O artigo termina com uma
lista dos principais requisitos que facilitariam o reforço
do financiamento da saúde e assim, a melhoria da
cobertura universal de saúde na Região.
Impact of performance-based
financing on health-care quality
and utilization in urban areas of
Cameroon. . . . . . . . . . . . . . . . . 10
2
Impact du financement basé sur la performance
sur la qualité et l’utilisation des soins de santé
dans les zones urbaines au Cameroun
RÉSUMÉ—Le présent article passe en revue un projet
pilote conçu pour estimer l’impact du financement basé
sur la performance (FBP) sur la qualité et l’utilisation des
soins de santé dans un environnement essentiellement
urbain, à savoir la Région du Littoral, au Cameroun. A
cet effet, il utilise trois méthodes quasi expérimentales
d’évaluation d’impact recourant notamment à
l’appariement et à la différence-dans-la différence. Les
résultats montrent que le projet pilote sur le FBP a eu un
impact positif et significatif sur la plupart des aspects
essentiels des soins de qualité. Par contre, il n’a eu aucun
impact sur tout autre indicateur d’utilisation des services
de santé, à l’exception (du reste limitée) des méthodes
contraceptives modernes. Ces conclusions donnent à
penser que l’environnement et les indicateurs choisis
revêtent une grande importance pour la réalisation d’un
impact maximum. Toutefois, il convient également de
noter que les améliorations dans l’utilisation des soins de
santé dans les zones urbaines pourraient être limitées,
en raison des niveaux élevés des données de référence.
Enfin, les conclusions montrent que la qualité des soins
semble être l’aspect le plus prometteur, en termes
relèvement du FBP en milieu urbain.
Impacto do financiamento baseado no
desempenho sobre a qualidade e a utilização
dos cuidados de saúde em zonas urbanas dos
Camarões
SUMÁRIO—O presente artigo analisa um
projecto-piloto concebido para calcular o impacto
do financiamento baseado no desempenho (sigla
em inglês - PBF) sobre a qualidade e a utilização dos
cuidados de saúde num contexto predominantemente
urbano – a região Litoral dos Camarões. O projecto
utiliza três métodos semi-experimentais de avaliação
de impacto que envolvem compatibilidade e diferença
em diferenças. Os resultados mostram que o projectopiloto de PBF teve um impacto positivo e significativo
na maioria dos aspectos essenciais da qualidade dos
cuidados. Ao mesmo tempo, não houve impacto em
quaisquer dos indicadores de utilização dos serviços de
saúde, à excepção (limitada) de métodos contraceptivos
modernos. Estas conclusões sugerem que o contexto e os
indicadores escolhidos são importantes para se conseguir
o máximo de impacto. No entanto, convirá notar que
as melhorias na utilização poderão ser limitadas em
resultado dos valores de referência elevados. Por último,
as conclusões indicam que a qualidade dos cuidados
parece ser o aspecto mais promissor em termos de
melhorias no que diz respeito aos contextos urbanos.
Institutions and structural quality
of care in the Ghanaian health
system. . . . . . . . . . . . . . . . . . . . 15
3
Institutions et qualité structurelle des soins dans
le système de santé ghanéen
RÉSUMÉ—Par qualité structurelle de la dispensation
des soins de santé, l’on entend la disponibilité des
ressources matérielles et humaines. L’insuffisance de
telles ressources au niveau des établissements de santé
se traduit par le manque de personnels, le grand nombre
de patients hospitalisés et en consultation externe,
et le manque des outils nécessaires pour garantir une
prestation appropriée des services de santé. Il y a un lien
très étroit entre la disponibilité de ces ressources et les
facteurs institutionnels, notamment la gouvernance et
les incitations visant à encourager le personnel. L’objectif
de la présente étude est de déterminer les effets des
facteurs institutionnels sur la qualité structurelle des
formations sanitaires publiques dans le système de
santé ghanéen. Les données émanant de nouvelles
enquêtes couvrant 62 formations sanitaires publiques
ont été utilisées pour établir trois indices pour la qualité
structurelle, à savoir la surcharge, le personnel et les
équipements. Trois hôpitaux étaient les plus confrontés
à une très grande surcharge de travail et souffraient le
plus de la pénurie de personnels, alors qu’ils disposaient
pourtant des équipements les plus performants. Il a
été établi que la performance interne revêtait une plus
grande importance dans les efforts visant à réduire
la surcharge, par rapport à la gouvernance externe.
A l’opposé, il y avait le cas de l’indicateur relatif aux
équipements. La pénurie de personnels était d’un
niveau moindre dans les formations sanitaires offrant
des possibilités de perfectionnement des compétences
professionnelles. L’étude a mis en lumière l’importance
d’une bonne coordination de l’administration des
formations sanitaires avec les personnels de santé, tout
comme avec l’administration, dans les efforts visant à
améliorer la qualité.
Instituições e qualidade estrutural dos cuidados
no sistema de saúde do Gana
SUMÁRIO—A qualidade estrutural na prestação
de cuidados de saúde diz respeito à disponibilidade
de recursos físicos e humanos. A escassez destes
recursos nas unidades de saúde conduz à falta de
pessoal, sobrelotação dos serviços ambulatórios e de
internamento, e à falta de ferramentas necessárias
para a prestação de cuidados de saúde adequados. A
disponibilização destes recursos está estreitamente
correlacionada com factores institucionais, mais
concretamente governação e incentivos ao pessoal de
saúde. Este estudo tem por finalidade explorar o efeito
dos factores institucionais na qualidade estrutural nas
unidades de saúde pública do sistema de saúde do Gana,
para o qual foram utilizados novos dados de inquérito
de 62 unidades de saúde pública de três regiões do
Gana. Utilizou-se uma análise dos componentes
principais para criar três índices de qualidade estrutural:
sobrelotação, pessoal e equipamento. Foram efectuadas
três regressões para índices de qualidade relativos aos
factores institucionais. Os resultados mostraram que os
hospitais nacionais eram os mais sobrelotados e tinham
as maiores faltas de pessoal mas dispunham do melhor
equipamento. Verificou-se que a governação interna
era mais importante que a governação externa para
reduzir a sobrelotação, sendo o contrário para o índice
de equipamento. Nas unidades com oportunidades
para o desenvolvimento profissional a falta de pessoal
era ligeira. O estudo realçou a importância da boa
coordenação da administração das unidades de saúde
com os trabalhadores, assim como com o governo, na
melhoria da qualidade.
69
Solidarity in community-based
health insurance in Senegal:
Rhetoric or reality?. . . . . . . . . . . 20
4
Solidarité dans l’assurance-maladie à base
communautaire au Sénégal: Rhétorique ou
réalité?
RÉSUMÉ—La persistance de faibles taux de couverture
par l’assurance-maladie à base communautaire (AMBC)
donne à penser que les stratégies de mise à échelle,
proposées par bon nombre de pays, n’ont pas été bien
conçues ou alors n’ont pas été mises en œuvre avec
succès. Une des raisons pouvant expliquer cette situation
est le manque d’intégration systématique du contexte
sociopolitique dans la politique de l’AMBC. Dans la
présente étude, la solidarité dans l’AMBC est analysée du
point de vue sociologique, afin de trouver des réponses
aux questions suivantes dans le cadre des recherches :
Quelles sont les définitions et les perceptions locales
de la solidarité dans l’AMBC ? Dans quelle mesure ces
définitions et perceptions locales relèvent-elles de la
pratique ? Trois études de cas portant sur les régimes
d’AMBC au Sénégal ont été examinées, en utilisant à cet
effet des critères précis. Les transcriptions d’entretiens
avec 64 acteurs de l’AMBC ont été analysées en utilisant
le codage inductif. Un cadre conceptuel axé sur quatre
dimensions de la solidarité (risque sanitaire, équité
verticale, échelle et source) a été élaboré aux fins
d’interprétation des résultats. Les résultats donnent
à penser que le concept de solidarité dans l’AMBC est
plutôt complexe. Chaque dimension ou source de la
solidarité était soit non ancrée dans la pratique, soit
fortement contestée, les vues divergeant du reste à cet
égard entre les parties prenantes et les populations
ciblées. Il y aurait donc lieu que les décideurs engagent
des discussions publiques plus rigoureuses sur le
concept de solidarité dans le contexte de l’AMBC et plus
généralement de la politique de couverture sanitaire
universelle, afin d’évoluer vers des politiques cadrant
avec les attentes des populations qu’elles entendent
desservir, tout en répondant à ces attentes.
Solidariedade no seguro de saúde de base
comunitária no Senegal: retórica ou realidade?
SUMÁRIO—As taxas persistentemente baixas de
adesão ao seguro de saúde de base comunitária (sigla
em inglês – CBHI) sugerem que em muitos países as
estratégias de incrementação propostas não foram
bem concebidas ou implementadas com êxito. Uma das
razões para o facto poderá ser a falta de incorporação
sistemática do contexto político e social na política do
CBHI. Neste estudo, a solidariedade no CBHI é analisada
numa perspectiva sociológica por forma a responder
às seguintes perguntas de investigação: quais são
as definições e percepções locais de solidariedade
no CBHI? Em que medida estas são corroboradas em
termos práticos? Foram analisados três estudos de casos
de regimes de CBHI senegaleses utilizando critérios
específicos e analisadas transcrições de entrevistas com
64 intervenientes nos CBHI, utilizando a codificação
indutiva. Desenvolveu-se um quadro conceptual das
quarto dimensões da solidariedade (risco de saúde,
equidade vertical, escala e fonte) para interpretar os
resultados. Os resultados sugerem que o conceito de
solidariedade no CBHI é complexo. Cada dimensão e
fonte da solidariedade não foi corroborada em termos
práticos ou foi altamente contestada, com as opiniões a
divergirem entre os intervenientes e a população visada.
Isto sugere que os decisores políticos precisam de encetar
um diálogo público mais rigoroso sobre a solidariedade
no que toca ao CBHI e à política geral da cobertura
universal de saúde, para se progredir no sentido da
70
elaboração de políticas que correspondam e satisfaçam
as expectativas das populações a que se destinam.
formas de tornar os prestadores privados de serviços para
o VIH numa parte mais integral dos esforços públicos
para criar uma resposta sustentável e dirigida pelos
países à epidemia do VIH.
Financing flows through private
providers of HIV services in subSaharan Africa. . . . . . . . . . . . . . 27
6
Flux de financements acheminés par le canal de
prestataires privés de services de lutte contre le
VIH en Afrique subsaharienne
RÉSUMÉ—Une importante stratégie de soutien des
efforts des pays en développement dans la lutte contre
le VIH et l’élargissement de l’accès aux services de santé
consiste à tirer pleinement parti du potentiel des acteurs
privés dans la gestion du financement de la santé et la
prestation des services de santé. Les auteurs ont utilisé
les données sur le suivi des ressources consacrées à
la santé et à la lutte contre le VIH en Côte d’Ivoire, au
Kenya, au Malawi et en Namibie pour évaluer la viabilité
du financement de la lutte contre le VIH dans ces pays
ainsi que pour comparer le niveau et l’origine des flux de
ressources en faveur des prestataires privés de services
de lutte contre le VIH, en accordant une attention
particulière aux charges financières à supporter par les
personnes vivant avec le VIH (PVV). Il ressort de leur
analyse que la lutte contre le VIH, dans tous ces quatre
pays, se heurte à des problèmes de durabilité et au
manque de moyens financiers des PVV recourant à des
prestataires privés de services de lutte contre le VIH.
Il en ressort également qu’en dépit de l’intérêt affiché
des donateurs pour l’engagement du secteur privé
et les partenariats public-privé, seule une très faible
proportion des financements parvient effectivement à
ces prestataires qui dépendent, dans une large mesure,
des frais payés directement par les PVV. À la lumière
de ces constatations, les donateurs et les acteurs
gouvernementaux dans ces pays devraient envisager
des moyens de mieux intégrer les prestataires privés de
services de lutte contre le VIH dans les efforts déployés
par les pouvoirs publics pour lutter durablement contre
l’épidémie de VIH, en fonction de la situation dans
chaque pays.
Premiers éléments de preuve émanant du
financement basé sur les résultats en milieu rural
au Zimbabwe
RÉSUMÉ—Le financement basé sur les résultats
(FBR) est une approche innovante du financement
des systèmes de santé, approche consistant à payer
les prestataires de services en fonction des résultats
obtenus. En juillet 2011, grâce à un don de la Banque
mondiale, le Zimbabwe a lancé un projet de FBR
pour améliorer le recours à des services de santé
maternelle, néonatale et infantile (SMNI) de qualité.
Le présent article est consacré aux résultats initiaux.
Une analyse statistique des districts couverts et des
districts témoins montre que les taux de couverture
des services SMNI dans les districts bénéficiant du
FBR sont plus élevés que dans les districts témoins.
Les taux de croissance en rythme mensuel des recours
aux soins anténataux et périnataux et les données sur
cette croissance sont d’importance du point de vue
des statistiques après l’intervention, contrairement à
la situation avant l’intervention, et aucune tendance
significative n’a été observée dans les districts témoins.
L’étude qualitative donne une idée des mécanismes
à travers lesquels le FBR a contribué à l’amélioration
de la performance, à la faveur de facteurs tels que
l’institution de contrats, l’autonomie accrue accordée
aux établissements de santé, l’implication accrue des
communautés, la motivation intrinsèque du personnel
chargé d’administrer les soins de santé, l’existence d’un
système d’information sanitaire fiable, l’abolition des
frais pour les patients, l’amélioration de la supervision
des établissements de santé, la séparation des tâches, et
la politique du Gouvernement zimbabwéen portant sur
la gestion axée sur les résultats (GaR).
Fluxos de financiamento através de prestadores
privados de serviços para o VIH na África
Subsariana
SUMÁRIO—Potenciar ao máximo os actores privados
para gerir o financiamento e prestar serviços de saúde
é uma importante estratégia para manter a resposta
nacional ao VIH e aumentar o acesso aos serviços nos
países em desenvolvimento. Os autores utilizaram
dados de acompanhamento dos recursos para a
saúde e o combate ao VIH da Côte d’Ivoire, Quénia,
Malawi e Namíbia para avaliar a sustentabilidade do
financiamento para o combate ao VIH nestes países e
comparar a dimensão e a origem dos recursos dirigidos
aos prestadores privados de serviços para o VIH, dando
especial atenção ao fardo financeiro que recai nas
pessoas que vivem com o VIH (PVVIH). As conclusões
indicam que as respostas para o VIH nesses quatro países
enfrentam desafios em matéria de sustentabilidade
assim como uma lacuna na cobertura financeira para
as PVVIH que procuram cuidados junto dos prestadores
privados. Não obstante os interesses declarados dos
doadores em envolverem-se com o sector privado e
em parcerias público-privadas, as conclusões indicam
igualmente que muito pouco do seu financiamento
acaba por chegar a estes prestadores, que são, ao invés,
maioritariamente financiados pelos pagamentos directos
das PVVIH. À luz destas conclusões, os doadores e os
actores governamentais nesses países deverão considerar
Primeiras evidências do financiamento com base
nos resultados nas zonas rurais do Zimbabwe
SUMÁRIO—O financiamento com base nos resultados
(sigla em inglês - RBF) é uma abordagem inovadora
ao financiamento dos sistemas de saúde, que paga aos
prestadores pelos resultados verificados. Em Julho de
2011, através de uma subvenção do Banco Mundial, o
Zimbabwe iniciou um projecto de RBF para melhorar
a utilização de serviços de saúde materna, neonatal e
infantil de qualidade. Este artigo analisa os primeiros
resultados. Uma análise estatística dos distritos
intervencionados e os distritos de controlo monstra
que os distritos RBF demonstram um maior aumento
dos níveis de utilização dos serviços de saúde materna,
neonatal e infantil do que os distritos de controlo. As
taxas mensais de aumento dos cuidados pré-natais,
encaminhamentos perinatais e a monitorização do
crescimento são estatisticamente significativas após
a intervenção, ao passo que antes desta, não o eram,
e não foi encontrada qualquer tendência significativa
nos distritos de controlo. O estudo qualitativo fornece
uma percepção dos mecanismos através dos quais o
RBF contribuiu para melhorar o desempenho: o uso
de contratos, uma maior autonomia das unidades de
saúde, um maior envolvimento comunitário, motivação
intrínsica dos profissionais de saúde, existência de um
sistema fiável de informação sanitária, abolição das taxas
moderadoras, melhor supervisão das unidades de saúde,
5
Early evidence from results-based
financing in rural Zimbabwe. . . 32
separação de funções e a política de gestão baseada nos
resultados do Governo do Zimbabwe.
Piloting a performance-based
financing scheme in Chad: Early
results and lessons learned. . . . 37
7
Régime pilote de financement basé sur la
performance au Tchad : Résultats initiaux et
enseignements tirés
RÉSUMÉ—Le Ministère de la Santé de la République
du Tchad a décidé d’instituer un régime de financement
basé sur la performance (FBP), en tant que projet pilote
dans huit districts des zones rurales, entre octobre
2011 et mai 2013. En se basant sur les données aussi
bien qualitatives que quantitatives collectées au
cours de la mise en œuvre de ce régime, la présente
étude en analyse les résultats initiaux et tire des
enseignements précieux devant guider la mise à échelle
de ce régime à l’avenir. Malgré certaines réserves
d’ordre méthodologique, les résultats montrent qu’en
général, au cours de la période considérée, l’accès aux
services de santé s’est amélioré, tout comme la qualité
des soins, même si la performance au titre de certains
indicateurs est d’un niveau moindre. Ces résultats positifs
sont conformes aux conclusions de nos entretiens sur
les dimensions qualitatives mettant en lumière les
changements intervenus dans l’administration des soins
ainsi que dans la gestion des établissements de santé
et la règlementation du système de santé. Par ailleurs,
la courte durée du projet laisse planer quelques doutes
sur la durabilité de ces changements. En conclusion,
notre étude souligne la nécessité d’évaluations et
de discussions fondées sur des bases factuelles, afin
d’adapter la conception du FBP au contexte et de mieux
guider la prise de décisions sur les régimes de FBP, aussi
bien pour sa phase pilote que pour son déploiement à
l’échelle nationale.
Gestão de um regime-piloto de financiamento
baseado no desempenho no Chade: resultados
iniciais e ensinamentos colhidos
SUMÁRIO—O Ministério da Saúde da República
do Chade decidiu introduzir uma estratégia de
financiamento com base no desempenho (sigla em
inglês - PBF) como projecto-piloto em oito distritos de
zonas rurais, de Outubro de 2011 a Maio de 2013. Com
base nos dados quantitativos e qualitativos recolhidos
durante a implementação deste regime, este estudo
visa analisar os resultados iniciais do regime e retirar
ensinamentos valiosos para informar a intensificação
futura da estratégia. A despeito de algumas limitações
metodológicas, os resultados indicam que o acesso
geral aos serviços de saúde e qualidade dos cuidados
melhoraram durante o período em apreço embora
alguns indicadores não tenham sofrido grande alteração.
Estes resultados positivos correspodem às conclusões das
nossas entrevistas qualitativas, que realçaram alterações
nas formas de prestação de cuidados, bem como na
gestão das unidades de saúde e na regulação do sistema
de saúde. Porém, os resultados variam substancialmente
entre regiões (norte e sul) e entre unidades. Além
disso, a curta duração do projecto levanta a questão
da sustentabilidade dessas mudanças. Em conclusão,
o nosso estudo frisa a necessidade de avaliações e de
discussões baseadas em evidências de modo a adaptar
a fórmula do regime de PBF ao contexto, e a melhor
informar as decisões políticas sobre regimes de PBF,
tanto na fase piloto como quando se considerar o seu
lançamento a nível nacional.
Estimating willingness to pay
for maternal health services:
The Kenya reproductive health
voucher programme. . . . . . . . . 43
8
Estimation de la disposition à payer pour les
services de santé maternelle : Le programme de
bons de santé génésique au Kenya
RÉSUMÉ—Dans le cadre d’une évaluation générale
du programme de bons pour la santé génésique au
Kenya, qui visait à en déterminer l’impact sur les
résultats en matière de santé, une étude a été conduite
sur la disposition à payer (DAP) dans le pays. L’objet
de la présente étude est de procéder à l’estimation
des valeurs DAP pour une large gamme de services
de santé génésique tels que les soins anténataux,
les soins à l’accouchement, les soins prénataux et le
planning familial. L’étude s’est également penchée
sur les effets du programme de bons sur les valeurs
déclarées de la disposition des personnes interrogées à
payer pour les services de santé génésique. Les femmes
recourant aux services de santé génésique, tant dans les
établissements de santé acceptant les bons que dans
ceux qui ne les acceptent pas, ont été interrogées sur leur
disposition à payer pour les services de santé génésique,
et les valeurs DAP ont été déterminées en recourant à
une méthode des préférences indiquées. L’étude montre
que les femmes interrogées étaient disposées à payer un
prix positif pour l’accès aux services de santé génésique.
Il ressort également des résultats que les bons ont un
effet ou constituent une expérience d’apprentissage
différentiel pour ce qui est de la disposition à payer
dans le cas des soins anténataux, des soins postnataux,
du planning familial et des services d’accouchement.
Une analyse plus poussée met également en lumière
les effets de nantissement et de référence, le coût du
bon ayant un impact sur les valeurs indiquées de la
disposition à payer. S’agissant des bons, l’analyse fait
par ailleurs état du potentiel en matière de conception
d’un mécanisme de paiement à échelle glissante pour le
ciblage efficace des couches les plus nécessiteuses de la
population, ce qui permettra aux usagers potentiels de
payer pour les services dans les limites de leur capacité
et de leur disposition à payer, tout en libérant des
ressources pour prendre en charge les couches les plus
pauvres au sein de la société.
Estimativas da disponibilidade para pagar por
serviços de saúde materna: o programa de senhas
para a saúde reprodutiva no Quénia
SUMÁRIO—Foi realizado um estudo sobre a
disponibilidade para pagar (sigla em inglês – WTP)
como parte de uma avaliação mais abrangente de
um programa de senhas para a saúde reprodutiva,
destinado a determinar os seus efeitos nos resultados
sanitários. O estudo pretendia calcular os valores de WTP
para uma variedade de serviços de saúde reprodutiva,
nomeadamente: cuidados pré-natais, parto, cuidados
pós-natais e planeamento familiar. O estudo procurou
igualmente investigar o efeito do programa de senhas
nos valores de WTP indicados pelos inquiridos para
os serviços de saúde reprodutiva. Perguntou-se às
mulheres que utilizam os serviços de saúde reprodutiva
em unidades que aceitam senhas e em outras que não
aceitam, sobre a sua WTP para os serviços de saúde
reprodutiva e estes valores foram obtidos através de
um método de indicação de preferências. O estudo
concluiu que as mulheres estavam dispostas a pagar
um preço positivo para aceder aos serviços de saúde
reprodutiva. Os resultados apontam também para um
efeito ou experiência de aprendizagem diferencial da
senha na WTP para serviços de cuidados pré-natais,
pós-natais, planeamento familiar e parto. As análises
posteriores também salientam os efeitos de dotação e
referência com os custos das senhas a terem impacto nos
montantes declarados da WTP. As conclusões apontam
para o potencial de se elaborar um mecanismo de escala
de pagamento flexível com direccionamento eficaz de
subsídios, tais como senhas, para os segmentos mais
carenciados da população. Isto permitirá aos potenciais
utilizadores pagarem por serviços no âmbito da sua
disponibilidade para pagar, ao mesmo tempo que
se libertam recursos destinados aos mais pobres da
sociedade.
Fondements de la résilience et de
la pérennité de la mutuelle de santé
Fandène, Sénégal . . . . . . . . . . . 51
9
Reasons for the resilience and longevity of the
Fandène mutual health scheme, Senegal
SUMMARY—Senegal’s universal health coverage (UHC)
strategy aims, among others, to increase the penetration
rate of mutual health organizations (MHO) to 65.5% in
2017. This study seeks to examine what accounts for the
resilience and longevity of the oldest rural community
mutual health organization in Senegal (Fandène MHO)
and to draw from this experience in UHC. The study is
founded on a case study with documentary research,
individual interviews and focus group discussions with
members, former members and officials of the Fandène
MHO between 2012 and 2013, data coding using QDA
Miner and thematic analysis. The resilience and longevity
of the Fandène MHO is explained by the conditions
governing its establishment, the characteristics of the
target population, expanded reciprocity, governance,
trust and critical awareness of its members, as well
as the quality of care. The Fandène MHO enhances
solidarity, access to quality care and, over the years, has
acquired the legitimacy that makes it a credible partner
for UHC. Some of its weaknesses reflect the difficulties
in achieving UHC through voluntary membership
and MHOs operating at a small scale. In the long run,
compulsory UHC and public financing would be more
appropriate for providing the population adequate,
equitable and lasting coverage.
Fundamentos da resiliência e da sustentabilidade
da associação mutualista Fandène, Senegal
SUMÁRIO—A estratégia senegalesa de cobertura
universal de saúde visa, entre outras coisas, aumentar
a taxa de penetração das associações mutualistas para
65,5 % em 2017. O objectivo deste artigo é de analisar
os fundamentos da resiliência e da sustentabilidade
da mais antiga associação mutualista comunitária
rural do Senegal (Fandène) e tirar ilações da sua
experiência para a cobertura universal de saúde. O
artigo baseia-se num estudo de caso com: pesquisa
documental, entrevistas individuais e grupos de reflexão
com os membros, ex-membros e responsáveis da
associação mutualista entre 2012–2013, codificação
de dados com o QDA-Miner e análise temática de
conteúdos. A resiliência e a sustentabilidade desta
associação mutualista explicam-se pelas condições da
sua criação, as características da sua população-alvo,
a reciprocidade alargada, a governação, a confiança
e a consciência crítica dos membros, assim como a
qualidade dos seus cuidados. A associação mutulista
privilegiou a solidariedade e o acesso aos cuidados de
saúde de qualidade, e conquistou, ao longo dos anos,
uma legitimidade que faz dela uma parceira credível
para a cobertura universal de saúde. Algumas das suas
fragilidades revelam as dificuldades encontradas para
71
a consecução da cobertura universal de saúde com
participações voluntárias e associações mutualistas de
pequena dimensão. A longo prazo, a cobertura universal
de saúde obrigatória e o financiamento público serão
mais indicados para garantir uma cobertura adequada,
equitativa e sustentável das populações.
Increasing equity among
community-based health insurance
members in Rwanda. . . . . . . . . 58
A
Accroître l’équité parmi les souscripteurs de
l’assurance-maladie à base communautaire au
Rwanda
SUMMARY—Le taux de couverture du régime
d’assurance-maladie à base communautaire (AMBC)
lancé par le Gouvernement du Rwanda est passé à
91 % de la population en 2010, contre 7 % seulement
en 2003. Initialement, tous les souscripteurs de l’AMBC
payaient les mêmes primes, indépendamment de leurs
revenus personnels, si bien que les citoyens les plus
pauvres éprouvaient des difficultés à payer leurs primes
(près de 1,50 dollar EU par personne). Il fallait donc
d’urgence un mécanisme permettant de garantir l’accès
aux soins de santé pour les couches les plus vulnérables,
tout en œuvrant à la promotion de l’équité entre tous
les assurés. Le Gouvernement du Rwanda a donc décidé
d’introduire un système de stratification basé sur la
situation socioéconomique de la population, système
appelé Ubudehe. De concert avec les partenaires, y
compris le Projet de renforcement des systèmes de
santé intégrés (IHHSSP), le Gouvernement du Rwanda a
mis en place une base de données classant les citoyens
rwandais en catégories, selon le niveau de leurs revenus.
Jusqu’à présent, des informations concernant 10 millions
de résidents, soit 96 % de toute la population du pays,
ont été enregistrées dans la base de données, facilitant
ainsi l’identification des couches les plus vulnérables
du point de vue socioéconomique (environ 25 % de la
population). L’identification des couches les plus pauvres
a été suivie d’une augmentation des fonds destinés à
l’AMBC, à la faveur de l’identification des individus ayant
une plus grande capacité à payer. La base de données
a ainsi permis d’améliorer la viabilité financière et les
capacités de gestion du régime de l’AMBC.
Aumentar a equidade entre os membros do
seguro de saúde de base comunitária no Ruanda
SUMÁRIO—O regime de seguro de saúde de base
comunitária (CBHI) lançado pelo Governo do Ruanda,
abrangeu 91% da população em 2010, começando
com 7% em 2003. Inicialmente, todos os membros do
CBHI pagavam as mesmas taxas, independentemente
do seu rendimento pessoal, e os cidadãos mais pobres
tinham dificuldade em pagar o seguro (quase 1,5 dólares
americanos por pessoa). Como tal, era urgentemente
necessário dispor de um mecanismo que garantisse o
acesso aos cuidados de saúde para os mais vulneráveis
e promovesse a equidade entre os membros. O
Governo do Ruanda decidiu introduzir um sistema de
estratificação baseado no estatuto socioeconómico da
população, conhecido como Ubudehe. Em conjunto
com os parceiros, incluindo o projecto de reforço dos
sistemas integrados de saúde (sigla em inglês - IHSSP),
o Governo do Ruanda desenvolveu uma base de dados
nacional que estratifica os seus cidadãos conforme o seu
rendimento. Até à data, a base de dados conta já com 10
milhões de registos de residentes, o que representa 96%
da população do Ruanda. Esta base de dados ajudou
a identificar as pessoas mais vulneráveis com base no
estatuto socioeconómico (cerca de 25% da população).
A identificação dos mais pobres possibilitou um
aumento dos fundos do CBHI graças à identificação dos
indivíduos que têm uma maior capacidade para pagar.
Por conseguinte, a base de dados melhorou a viabilidade
financeira e a capacidade de gestão do regime do CBHI.
L’impact des modalités
d’allocation des ressources dans
les mécanismes d’exemption sur
l’équité : Plan Sésame,
Sénégal. . . . . . . . . . . . . . . . . . . 63
B
Impact of resource allocation arrangements on
equity exemption mechanisms: Plan Sésame,
Senegal
SUMMARY—The majority of exemption policies in
sub-Saharan Africa provide, de facto, for so-called
passive resource allocation arrangements. Plan Sésame
– an exemption mechanism adopted in Senegal in
2006 and targeting those aged over 60 years – is no
exception to this rule. It is based on user fees as a service
purchase method. This article examines the effects of
the passive service purchase method on equitable access
to care under Plan Sésame. The analysis is based on a
household survey conducted in Senegal from May 2012
to July 2013. It uses a mixed methodology, combining
review of policy documents, stakeholder analysis and a
household survey. The findings show that Plan Sésame is
characterized by hybrid funding, which advantages older
persons in the formal sector who have greater access to
hospitals. It is thus these people who capture the larger
proportion of the budget allocated under the Plan. In
sum, the most advantaged social groups and persons
living in urban areas stand a greater chance of accessing
Plan Sésame resources.
Modalidades de afectação de recursos nos
mecanismos de isenção e o seu impacto sobre a
equidade: Plano Sésamo, Senegal
SUMÁRIO—A maior parte das políticas de isenção na
África Subsariana aplicam, efectivamente, modalidades
ditas passivas de afectação de recursos. O Plano Sésamo,
um mecanismo de isenção adoptado no Senegal em
2006, destinado aos cidadão com idade igual ou superior
a 60 anos, não foge à regra: baseia-se no pagamento
directo como modalidade de aquisição de serviços. Este
artigo pretende explorar o efeito desta modalidade
passiva de aquisição de serviços na equidade do acesso
aos cuidados do Plano Sésamo. A nossa análise assenta
num inquérito realizado no Senegal entre Maio de
2012 e Julho de 2013. Utilizou-se uma metodologia
mista incluindo uma revisão de documentos de política,
uma análise das partes interessadas e um inquérito
aos agregados familiares. Os resultados mostram que
o Plano Sésamo caracteriza-se por um financiamento
híbrido que privilegiou as pessoas idosas que recorrem
ao sector formal e têm um melhor acesso aos hospitais,
os quais captaram uma grande parte dos orçamentos
afectados ao Plano Sésamo. Em suma, as camadas sociais
mais favorecidas e as que residem nos meios urbanos
têm mais oportunidades de acederem aos recursos do
Plano Sésamo.
The Post-2015 African Health Agenda and UHC: Opportunities and challenges, the third AfHEA international scientific conference, Kenya, March 2014 (see page 2).
72
The African Health Monitor
Special Issue 20 • October 2015
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Issue - African Health Observatory

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