Fee exemption policies for maternal health services
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Fee exemption policies for maternal health services. A Review of 11 African countries Benin, Burkina Faso, Burundi, Ghana, Mali, Morocco, Niger, Nigeria, Kenya, Senegal, Sierra Leone Fabienne Richard, ITM Antwerp & Matthieu Antony, CERDI Clermont-Ferrand. Purpose of the review.

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Fee exemption policies for maternal health services

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Fee exemption policies for maternal health services

Fee exemption policies for maternal health services

A Review of 11 African countries

Benin, Burkina Faso, Burundi, Ghana, Mali, Morocco, Niger, Nigeria, Kenya, Senegal, Sierra Leone

Fabienne Richard, ITM Antwerp & Matthieu Antony, CERDI Clermont-Ferrand


Purpose of the review

Purpose of the review

  • 1st objective:Compare the benefits package covered by the fee exemption policies across the three dimensions of universal coverage:

    • The breadth (percentage of population covered )

    • The depth (range of services covered)

    • The height (proportion of coveredcosts)

2


The three dimensions of universal coverage

The three dimensions of universalcoverage:

Exemption policy coverage

Couverture de la politique d’exemption

3


Purpose of the review part 2

Purpose of the review (part 2)

  • 2nd objective :

    Compare the funding modalities of these targeted policies

    • Reimbursement system for health facilities

    • Estimation of the budget envelope at national level

    • Forecast versus disbursed budget

4


Methodology

Methodology

  • Questionnaire developed by the FEM Health team with validation by the workshop organizing committee (2 parts: content and funding)

  • Pre-test in Burkina Faso

  • Sent to all countries that participated at the workshop by email to a key informant at central level

  • Follow-up by telephone and email

  • Comparative analysis of 11 sheets

5


Result of part 1

Result of part 1


Chronology of the policies introduction

Chronology of the policies introduction

Kenya

Phase 1

Senegal

Phase 2

Nigeria

Phase 1

Ghana

Phase 2

Burundi

Child under 5, Delivery, C-.Section

Kenya

Phase 2

Burundi

Pregnancy-related diseases

Senegal

Phase 1

Niger

Ghana

Phase 3

Nigeria

Phase 2

Ghana

Phase 1

Mali

Burkina Faso

C-section

Burkina Faso

Delivery

Morocco

Benin

Sierra Leone

Kenya

Phase 3

2004

2005

2006

2007

2008

2009

2010

2011

7


Who is covered

Benin

Mali

Senegal

Burkina Faso

Burundi

Ghana

Kenya (according to income)

Morocco

Niger

Nigeria

Sierra Leone (+ breastfeeding women)

Who is covered?

8


In what area of the country

Kenya: some regions only

Nigeria: some regions only

Senegal: Dakar not covered

Benin

Burkina Faso

Burundi

Ghana

Morocco

Mali

Niger

Sierra Leone

In what area of the country?

Targeted regions

Everywhere

9


In which hospitals

In which hospitals?

KenyaGhanaNigeria*

* except at tertiary level hospitals

Benin Burkina Faso

Burundi

10


Which services are covered

Which services are covered?

Covered by another exemption or subsidy policy

DC = Directs obstetric Complications

Hyster= hysterectomy

Ect.P = Ectopic Pregnancy

+++

++

+

11


Costs covered by the fee exemption or subsidy policies

Costs covered by the fee exemption or subsidy policies

* Emergency Medical Services (EMS) rural in Morocco in isolated areas

12


Proportion of covered costs

Proportion of covered costs

  • The majority of countries cover 100% of the costs of target services under the policy

  • 2 countries require some co-pay for direct costs of targeted services

    • Burkina Faso (80% of directs costs)

    • Kenya (ticket between 1 to 2 $)

13


System set up to comply with different referral levels

System set up to comply with different referral levels

  • Burkina Faso:

    • Delivery reimbursement = 80% in health centre and district hospitals

    • Reimbursement = 60% in regional and national hospitals

  • Morocco:

    • Exemption policy applied in UHC only for referred women

14


A multitude of targeted exemption policies

A multitude of targeted exemption policies

Most countries also have a national policy to cover the indigent, but they are not always implemented in practice.

* Ghana has exemption for Children under 18 enrolling onto the NHIS.

15


Synthesis

Synthesis

  • The minimum in common in the 11 countries is the management of Caesarean section

  • Other obstetric complications:

    • 2 countries do not cover other obstetric complications during labour and interventions other than Caesarean section

    • 4 countries do not cover postnatal complications

  • Transport costs:

    • Only Morocco covers transport from home to the health facility through rural EMS (in 24 provinces with difficult access)

    • Only 5 of 11 countries cover the costs of transportation between health facilities

  • Targeting the poorest:

    • The majority of policies apply to the entire population of pregnant women regardless of their income except for Kenya (policy targets poor pregnant women).

16


Complexity and variety of strategies

Complexity and variety of strategies

  • There is no single common strategy for fee exemption policies for maternal and child health care = no cut and paste, each country has a different system.

  • The majority of these policies do not cover all maternal and neonatal care so it is always partially paid for by the patient/family.

  • Exemption policies for maternal and neonatal care are not unique:

    • Several other exemption policies target other diseases or populations.

    • Several countries are simultaneously developing a national health insurance system

  • Complex architecture for fee exemption policies:

    • Do health personnel see their place in it? Do populations?

    • Is there coordination among these different targeted exemption policies?

    • Is there coordination among these fee exemption policies and institutional framework being set up for health insurance ?

17


Targeted exemption policies can we do better

Targeted exemption policies :can we do better?

Pregnant womenUnder fiveElderly…

C-section & DeliveriesTB, Malaria, HIVFamily Planning

Health centre

Hospitals, 1st, 2nd, 3rd level?


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