Key messages from AfHEA’s 2011 conference

1. Di McIntyre Chair, AfHEA Scientific Committee Key messages from AfHEA’s 2011 conference

2. Towards universal coverage • Universal coverage is on the agenda of many African countries • Universal coverage includes: • Financial protection from costs associated with health care • Protection of use of / access to needed health services

3. Financial protection • High out-of-pocket payments • Even more evidence of catastrophic payments • Growing recognition of the magnitude of other direct payments (especially transport costs)

4. User fee removal • Overall and particularly for specific programs (e.g. MCH- focus on the most vulnerable) • Adverse staff impact (increased workload) • Drug stock-outs • Sometimes replaced by unofficial fees • Continued high out-of-pocket payments (to private providers) • Fragmentation and confusion for implementers with multiplicity of exemption mechanisms

5. User fee removal continued • Implementation needs to be carefully planned and phased in – avoid ‘decree’ implementation • Need to increase pre-payment funding (for additional staff, drugs etc.) to accommodate utilisation increases

6. CBHI / covering the informal sector • Possibly greatest challenge facing our countries • Strong evidence that insurance contributions by informal sector is regressive • Still excluding the poorest • Willingness- and ability-to-pay lower than current premiums • Often don’t cover inpatient care where potential for catastrophic payments greatest

7. Cbhi / covering the informal sector • Need to be perceived benefits (good quality services) • Social networks contribute to extending coverage – draw on national social structures • Government / tax subsidies critical, but how to identify the poor: • Geographic targeting (high poverty area) • Proxy means testing

8. Improved domestic public funding ? • Innovative financing (Gabon) • Improve efficiency and equity in use of public funds: • Include poverty measures in resource allocation (vertical equity)

9. Service access and use • Benefits of using health services pro-rich • Key access barriers: • Distance to facility / transport (referral, emergency) • Inadequate staffing, especially in rural areas (recruiting from rural areas, better educational opportunities, free housing) • Inadequate drug supplies • Staff attitudes (some staff motivation interventions) • Access affects take-up of insurance (CBHI)

10. Performance based funding • Linking financing with service outputs has increased quantity of targeted outputs • Can contribute to wider range of reforms • Transactions costs can be high • Need for roles and responsibilities of all actors to be clearly defined • How to move funding from an external partner to national and sub-national authorities

11. Economic evaluation • Importance of identifying cost-effective interventions to inform key programs • Costs of scaling-up key interventions

12. Policy process and actors • Political leadership critical • Three pools of knowledge that need to be harnessed : researchers, practitioners and policy makers

13. Personal observations • Highlighting the problems • Describing the interventions: • Good to learn from each other’s experiences • Context matters • Limited evidence on impact of key reform interventions: • Does it work? • Why or why not? • Some large gaps (domestic public funding)

14. Other issues • AfHEA to invite participation of researchers from other continents, especially other LICs to share experiences • African researchers are still under-represented in the international health literature; • Need to encourage new and emerging talents in Africa / contribute to capacity development • Clarify link between country and regional associations and AfHEA

15. Thank you,Merci