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

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 ?

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

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  1. The access of poor people to health services in French speaking Africa Alain Letourmy (CERMES-CNRS) Antwerp, 18 December 2003 A. Letourmy, CERMES- CNRS, Antwerp, 18 December 2003

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

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

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

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

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

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

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

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

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

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

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

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

  14. 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

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