Revitalizing Community-Based Health Financing in Africa

1. Revitalizing Community-Based Health Financing in Africa Cheikh Mbengue October 26, 2009 USAID/Washington

2. Outline for presentation • Why CBHF? • Trends in CBHF and USAID technical approach in Africa • Lessons and opportunities • New CBHF strategy for Africa • Application in Niger and Mali • Expected outcomes

3. Out-of-pocket expenditures dominate health financing in Africa and Asia

4. Why should USAID support CBHF in Africa? • 44% of total health expenditures in Africa come directly from households out-of-pocket (OOP) • OOP: impoverishing, inefficient, limit access to care • Traditional health insurance is hard to establish where: • Economy is dominated by informal sector • Majority of population is rural poor • Influx of external health funding has been stymied by limited absorptive capacity

5. Why should USAID support CBHF in Africa? • CBHF formed the basis for scaling up to national insurance coverage in both Ghana and Rwanda • CBHF can effectively reach informal sector and vulnerable populations • Other international donors (World Bank, ILO, GTZ) are becoming more open to “mixed models” for insuring populations

6. CBHF trends in Africa • CBHF movement is active in West and East Africa • Spectrum of CBHF scale-up as of 2009: • Moving towards universal coverage/integration into national health insurance schemes: Ghana, Rwanda • Growing population coverage: Senegal, Benin, Mali • Incipient efforts: Burkina, Cameroon, Cape Verde, Ethiopia, Guinea, Mauritania, Niger, Togo

7. USAID has used a variety of approaches to support CBHF • Centrally-funded project support (PHR, PHRplus, PRIME 2) • Individual grassroots TA to MHOs; development of “toolkits”; research to evaluate effectiveness, and support to regional network La Concertation • Regional project support – AWARE-RH • Mixture of TA to “MHO support organizations,” national policy development, and support to regional network La Concertation • Bilateral project support, e.g. Senegal, Rwanda, Benin • Rwanda: TA to MHOs through district-level networks of MHOs and local governments • Senegal: TA to MHOs through NGOs and subnational networks of MHOs • Benin: TA to MHOs through support to district-level networks of MHOs and partnerships with local governments

8. USAID has used a variety of approaches to support CBHF

9. What are some lessons learned? • Supportive policy environment and institutional arrangements are essential to facilitate rapid scale-up • Government involvement and ownership is essential • Different donors, organizations, and project mechanisms can effectively provide complementary inputs • Constant need for program promotion when insurance membership is voluntary • Capacity to implement CBHF is limited at all levels • TA to individual schemes (especially by external consultants) is very labor intensive, expensive, and not locally sustainable • Need for monitoring to manage risk, quality, and sustainability • Need for evaluation to measure impact

10. What are the gaps / opportunities? • Lack of local capacity to implement national CBHF strategies • National networks that advocate for the implementation of the strategiesare weak • Existing MHOs are not receiving the systematic support they need to become sustainable, expand coverage, or create networks with other MHOs • Piecemeal health financing reforms • Abolition of user fees – can increase access but may diminish consumer interest in insurance, hurt service quality at the facility level, and lead to informal fees • Incipient national health insurance – how to integrate existing CBHF schemes?

11. What strengths do we have to build on? • Technical tools to support the development of integrated health insurance models, including MHOs (e.g. training manuals, guidelines) • Trained international and local personnel with grassroots- and national-level experience • National strategies as models for the way forward (Benin, Senegal, Rwanda, Ghana) • Explosive interest in health insurance and growing consensus that CBHF can be part of the health insurance scale-up • Other key donors such as ILO, GTZ, French Cooperation, Belgian Cooperation, and European NGOs are active and engaged ---- what is the way forward for USAID?

12. The way forward – CBHF strategy for Africa • Strengthen institutional capacity at the national and intermediate levels to advocate for and drive implementation of national strategies • Local government agencies – e.g. municipal and district authorities in Rwanda • Local/sub-national networks of MHOs – e.g. MHO networks in Benin • National network – e.g. CNC in Niger • Develop national strategic plans where they do not yet exist (e.g. Mali) • Replace user fees with premium payments to CBHF schemes to promote membership and sustain financing for service providers • Find out what works– Assess the relative effectiveness of supporting MHO development through national networks, national NGOs, and local MHO networks

13. Strategy: Provide support at the national and intermediate levels for CBHF scale-up in selected countries Regional and national policy development Local NGO and government capacity to implement national strategies and provide sustainable technical support to grassroots MHOs Health Systems 20/20 Expensive external TA to individual MHOs

14. Strategy: Integrate user fee policies with CBHF to promote membership, sustain financing for service providers User fees w/o CBHF Provider $200

15. Strategy: Integrate user fee policies with CBHF to promote membership, sustain financing for service providers Free care w/o CBHF User fees w/o CBHF Provider $100 Provider $200

16. Strategy: Integrate user fee policies with CBHF to promote membership, sustain financing for service providers Free care w/o CBHF User fees w/o CBHF Provider $100 Link user fees w/ CBHF MOH allocates $100 Provider $200

17. CBHF Strategy for Africa: Applications in Niger and Mali

18. Niger’s national CBHF strategy not implemented • Rapid assessment of current status of CBHF • National CBHF strategy in place since March 2008 • Not implemented due in large measure to lack of implementation capacity and resources • Health Systems 20/20’s approach: • Foster partnership between Gov’t of Niger and CNC (national network of organizations that support MHOs) • Strengthen CNC’s capacity to implement national strategy

19. Niger strategy in action • Conducted a national-level workshop to develop the advocacy skills of CNC members • Working with the Government of Nigerand CNC to develop an operational plan to implement the national strategy • Planning a workshop to strengthen the capacity of CNC and NGOs staff to create and support MHOs

20. Expanding CBHF in Mali • No prior national strategy for CBHF • Piecemeal reduction of user fees • Ministries of Social Welfare (MSW) and Health (MOH) have overlapping interests • Government wants to expand CBHF and subsidize premiums for the poor Health Systems 20/20’s strategy • Partner with MOH, MSW, and international donors to develop and implement a national strategic plan for CBHF scale-up

21. Mali strategy in action Results to date: • Health Systems 20/20 partnering with Gates-funded Ministerial Leadership Initiative and World Bank • Working closely with MOH and MSW to develop strategic planning process • Conducted first of two national-level consultations to develop the plan • Subcontracted with UTM, a key national NGO created by Malian MHOs, to strengthen three MHOs in Sikasso Next steps: • Second national consultation on Mali’s national CBHF strategy • Develop a plan to operationalize the strategy • Continue strengthening of MHOs in Sikasso through UTM • Through UTM (and in partnership with the regional office of the MSW and NGOs) develop an MHO network in Segou Region for existing MHOs

22. Expected regional and country outcomes • Concrete on-the-ground impact in Mali and Niger • More and stronger CBHF schemes, more people covered, local capacity strengthened to implement CBHF • Lessons learned about how to strengthen local implementation capacity to expand and sustain CBHF coverage • New tools for local organizations • Assessment framework for CBHF scale-up • Assessment of existing MHO performance • Roadmap to establish a sub-national network of MHOs • Sample operational plans for national CBHF strategies

23. Thank you. For more information visit www.healthsystems2020.org