a. letourmy, cermes- cnrs, antwerp, 18 december 2003 the access of poor people to health services in...

A. Letourmy, CERMES- CNRS, Antwerp, 18 December 2003

The access of poor people to health services in French speaking Africa

Alain Letourmy (CERMES-CNRS)

Antwerp, 18 December 2003


Plan of the presentation

• 1- Health policies concerning poor people in West Africa

• 2- How to give poor people access to health services when they are sick ?

• 3- How to give poor people access to health insurance ?


1-1Health policies and consequences for poor people

• Two constraining elements with regard to the access of poor people to health services : cost recovery and reforms establishing the financial autonomy of health care facilities

• The Bamako Initiative : an improvement or a supplementary barrier for poor people ?

• Financial autonomy : payment of users and cost control as more important issues for health care facilities, especially for hospitals

• Consequence : illusion of social prices (eg real user cost of a caesarian delivery in Burkina)


1-2 Special policies towards poor people

• Free access (re)established for certain categories of users : in case of specific diseases (AIDS, TB, etc.), for pregnant women, for infants, for poor people

• The obligation of care in case of emergency, even if people cannot pay

• The specific procedures concerning poor people :– certificates of indigence– ear-marked budgets allocated to health care facilities


1-3 The effectiveness of special policies

• The global result is a financial burden for health care facilities

• What effectiveness for poor people ?• False indigents • Commitment without payment for the institutions

delivering certificates• The new behaviour of health care facilities when

they receive ear-marked budgets : moral hazard (RCI)


2-1 Some experiments and projects to give poor people access to health services

• Two kinds of solutions : general ones and local ones

• Local ones : “Caisses de solidarité” (Solidarity funds) and Selingue experimentation (Local Medical Assistance Fund)

• General ones : National Medical Assistance Fund (Mali)


2-2 Local solutions : Solidarity Funds (Caisses de solidarité) in

Mali)

• Goal : a better organisation of referrals in case of dystocy ie access to the adequate level

• Cost sharing between upper level (district), primary care unit (ASACO) and user

• Results : improvements in terms of maternal mortality

• Dissemination and project of implementing mutual societies in order to share the risk

• Question : exclusion of very poor people ?


2-3 Local solutions : the Medical Assistance Fund in Selingué

• Indigent defined as people without means of payment when they are sick

• Fund gathering resources from different partners (local authorities, external donors, the State)

• Social investigation achieved by the social services associated with the health care unit

• Decision by an ad hoc committee : payment for the indigent or loan (that is to be reimbursed)

• Results : less than 2% of the users of the health care centre are concerned ; the rate of reimbursement is more than 50%


2-4 General solution : a National Medical assistance fund

• Definition of indigent people : non statutory but pragmatic, depending upon the situation

• Institutions providing the resources : the decentralized authorities, the State, the insurance schemes

• Decentralized management, but general rules concerning the covered basket of services, the way of determining the exempted people, etc.

• National evaluation and control• Questions, debates and conflicts : the institutional nature of local

management (local board of the fund, local authority, mixed organisation) ; the repartition of the funding between the State, the decentralized authorities and the others.


3-1 Poor people as a vulnerable population

• The promotion of health micro insurance and especially mutual health societies

• The limit : the payment of the contribution

• Insurance excludes very poor people

• Is it possible for poor people to get an access to health insurance ?


3-2 Local solutions

• 1st example (Nongon) : collective payment of the contributions based on the crop of cotton

• 2nd example (rural MHS in Borgou, Benin)) : automatic inclusion of poor people in some villages where MHS are implemented

• 3rd example : the linkage of micro insurance and micro finance (or micro enterprises) makes easier the access to health insurance (ex : Koulikoro and Kènèya So)


3-3 Limits to local solutions

• The community level is the adequate level for the identification of indigent people and the expression of traditional solidarity. It is inadequate in terms of risk pooling

• MHS are attracting people with resources higher than the resources of the population : are these people ready to give a subsidy to the poorest ?


3-4 General (virtual) solutions

• Universal coverage : questions to national projects (Ivory Coast, Gabon, Kenya)

• IC : differences between the rural scheme and the urban scheme

• Allowances to mutual health societies

• Individualized payment of the contributions to the MHS for poor families


Conclusion : problems and questions

• Definition of indigents : differences between the 2 kinds of solutions (direct access and insurance)

• Advantages of insurance ? Differences between poor and ultra poor people

• The role of the supply of health services

a. letourmy, cermes- cnrs, antwerp, 18 december 2003 the access of poor people to health services in...

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