Valéry Ridde

A scoping review of the literature on the abolition of user fees in health care services in Africa.

In Africa, user fees constitute a financial barrier to access to health services. Increasingly, international aid agencies are supporting countries that abolish such fees. However, African decision-makers want to know if eliminating payment for services is effective and how it can be implemented. For this reason, given the increase in experiences and the repeated requests from decision-makers for current knowledge on this subject, we surveyed the literature. Using the scoping study method, 20 studies were selected and analysed. This survey shows that abolition of user fees had generally positive effects on the utilization of services, but at the same time, it highlights the importance of implementation processes and our considerable lack of knowledge on the matter at this time. We draw lessons from these experiences and suggest avenues for future research.

Determinants of utilisation of maternal care services after the reduction of user fees: A case study from rural Burkina Faso

OBJECTIVE To identify determinants of utilisation for antenatal care (ANC) and skilled attendance at birth after a substantial reduction in user fees. METHODS The study was conducted in the Nouna Health District in north-western Burkina Faso in early 2009. Data was collected by means of a representative survey on a sample of 435 women who reported a pregnancy in the prior 12 months. Two independent logit models were used to assess the determinants of (a) ANC utilisation (defined as having attended at least 3 visits) and (b) skilled assistance at birth (defined as having delivered in a health facility). RESULTS 76% of women had attended at least 3 ANC visits and 72% had delivered in a facility. Living within 5 km from a facility was positively associated, while animist religion, some ethnicities, and household wealth were negatively associated with ANC utilisation. Some ethnicities, living within 5 km from a health facility, and having attended at least 3 ANC visits were positively associated with delivering in a facility. CONCLUSIONS User fee alleviation secured equitable access to care across socio-economic groups, but alone did not ensure that all women benefited from ANC and from skilled attendance at birth. Investments in policies to address barriers beyond financial ones are urgently needed.

Removing user fees in the health sector: a review of policy processes in six sub-Saharan African countries

In recent years, governments of several low-income countries have taken decisive action by removing fully or partially user fees in the health sector. In this study, we review recent reforms in six sub-Saharan African countries: Burkina Faso, Burundi, Ghana, Liberia, Senegal and Uganda. The review describes the processes and strategies through which user fee removal reforms have been implemented and tries to assess them by referring to a good practice hypotheses framework. The analysis shows that African leaders are willing to take strong action to remove financial barriers met by vulnerable groups, especially pregnant women and children. However, due to a lack of consultation and the often unexpected timing of the decision taken by the political authorities, there was insufficient preparation for user fee removal in several countries. This lack of preparation resulted in poor design of the reform and weaknesses in the processes of policy formulation and implementation. Our assessment is that there is now a window of opportunity in many African countries for policy action to address barriers to accessing health care. Mobilizing sufficient financial resources and obtaining long-term commitment are obviously crucial requirements, but design details, the formulation process and implementation plan also need careful thought. We contend that national policy-makers and international agencies could better collaborate in this respect.

The national subsidy for deliveries and emergency obstetric care in Burkina Faso.

INTRODUCTION To reduce financial barriers to health care services presented by user fees, Burkina Faso adopted a policy to subsidize deliveries and emergency obstetric care for the period 2006-2015. Deliveries and caesarean sections are subsidized at 80%; women must pay the remainder. The worst-off are fully exempted. METHODS The aim of this article is to document this policys entire process using a health policy analytical framework. Qualitative data are drawn from individual interviews (n = 113 persons) and focus groups conducted with 344 persons in central government, three rural districts and one urban district. Quantitative data are taken from the national health information system in eight districts. RESULTS The policy was initiated in all districts concurrently, before all the technical instruments were ready. The subsidy is paid by the national budget (US

Per diems undermine health interventions, systems and research in Africa: burying our heads in the sand

60 million, including US

A literature review of the disruptive effects of user fee exemption policies on health systems

10 million for the worst-off). Information activities, implementation and evaluation support have been minimal because of insufficient funding. Health workers and lay people have not always had the same information, such that the policy has not been uniformly applied. Coping strategies have been noted among health workers and the population, but there has been no attempt to impede the policys implementation. At the time of the study, fixed-rate reimbursement for delivery (output-based) and overestimation of input costs were financially advantageous to health workers (bonuses) and management committees (hoarding). Very few of the worst-off have been exempted from payment because selection processes and criteria have not yet been defined and most health workers are unaware of this possibility. The upward trend in assisted deliveries since 2004 continued after the policys introduction. CONCLUSIONS This ambitious policy expresses a strong political commitment but has not been adequately supported by international partners. Despite relatively tight administrative controls, health workers have figured out how to take advantage of the system. Some of the policys instruments should be reviewed and clarified to improve its effectiveness.

A community-based targeting approach to exempt the worst-off from user fees in Burkina Faso

keywords: perdiems, incentives, research, Africa, aidAcute ‘perdiemitis’ is decidedly one of the most prevalentillnesses in African public health projects. When a novice(African or Westerner) first undertakes a research projector implements a public health intervention, he willencounter the diplomatically phrased question: ‘Whatare the administrative modalities?’ These days, anyoneattending a research results presentation workshop, atraining session, or an intervention expects that theorganizers will pay him a premium – a per diem – for hisparticipation. While per diems appear to have beenoriginally used to compensate for the loss of time andincome caused by such participation, today they havebecome political instruments that taint research andintervention activities. If some expect that Africa will notachieve the Millennium Development Goals by 2015(Murray et al. 2007), we believe per diems are contributingto that expected failure (without, of course, explaining itentirely), because they reduce the potential effectiveness ofinterventions and dilute health sector resources. While thiscommentary is focused on the health sector, it should beclearly noted that the issue of per diems also affects otherareas such as housing construction (Ba¨hre 2005), economicdevelopment (Phonphakdee et al. 2009) and water supply(Bradley & Karunadasa 1989). The aim of this commen-tary is not to throw stones at anyone in particular. Rather,it is to bring to light this phenomenon, known to all butseldom mentioned and little studied (Vian 2009), to suggesta deliberative process (Culyer & Lomas 2006) to find anequitable treatment for this long-neglected disease.The arrival of per diems and the reasons behind themWhile the history of per diems remains to be written, itappears these practices arose at the end of the 1970s withthe growth of development aid. Up to then, healthworkers carried out their activities and were remuneratedwith their salaries and no other payments except fortravel costs. They were often hosted in remote regions bytheir colleagues or by villagers, who housed and fed them.Then, the massive arrival of the development industrygave rise to new funding modalities. In these developmentprojects, very well-paid expatriate aid workers carried outactivities with their African colleagues who were muchless well paid. Thus, the aid workers introduced these perdiems, perhaps out of ethical concerns, but mainlymotivated by a desire for effectiveness, to ensure theseactivities would take place. As the years went by, habitswere formed, and the practice was institutionalized; eventhe Financial Times called it ‘the culture of the ‘per diem’’(Jack 2009). Today, it has practically become a right, andsome States (e.g. Niger, Mali, Burkina Faso) even legislateon the subject.For example, in 2007 in Burkina Faso, five presidentialdecrees dealt with project functioning and the standardi-zation of per diem rates. The hierarchy of per diems wasestablished, with drivers receiving less than project coor-dinators, even though they might be assumed to have thesame needs for food and lodging. However, donor agencieswere not willing to ‘align’ themselves (to use the ParisDeclaration terminology) with these amounts; nor werethey able to agree on an alternative. In early 2010, in Mali,the United Nations agencies standardized their rates bydistributing an official rate schedule for the country’s civilservants. They thereby formalized the fact, for instance,that someone attending a training session in the capital, hiscity of residence, must receive an amount equivalent to

The impact of targeted subsidies for facility-based delivery on access to care and equity – Evidence from a population-based study in rural Burkina Faso

10US (5000 F CFA) for transportation costs. Article four ofDecree 779 in Burkina Faso, in 2007, ratified exactly thesame principles and the same amount. It thus becamedifficult to organize training sessions without paying theattendees, or to hold a press conference without paying thejournalists.

Transferability of interventions in health education: a review.

BackgroundSeveral low- and middle-income countries have exempted patients from user fees in certain categories of population or of services. These exemptions are very effective in lifting part of the financial barrier to access to services, but they have been organized within unstable health systems where there are sometimes numerous dysfunctions. The objective of this article is to bring to light the disruptions triggered by exemption policies in health systems of low- and middle-income countries.MethodsScoping review of 23 scientific articles. The data were synthesized according to the six essential functions of health systems.ResultsThe disruptions included specifically: 1) immediate and significant increases in service utilization; 2) perceived heavier workloads for health workers, feelings of being exploited and overworked, and decline in morale; 3) lack of information about free services provided and their reimbursement; 4) unavailability of drugs and delays in the distribution of consumables; 5) unpredictable and insufficient funding, revenue losses for health centres, reimbursement delays; 6) the multiplicity of actors and the difficulty of identifying who is responsible (‘no blame’ game), and deficiencies in planning and communication.ConclusionsThese disruptive elements give us an idea of what is to be expected if exemption policies do not put in place all the required conditions in terms of preparation, planning and complementary measures. There is a lack of knowledge on the effects of exemptions on all the functions of health systems because so few studies have been carried out from this perspective.

Communities of practice: the missing link for knowledge management on implementation issues in low-income countries?

Background: To contend with the risk of exclusion created by user fees, those implementing the Bamako Initiative (BI) were asked to organise exemption schemes for the indigent. But those exemption schemes were never put in place in Africa due to difficulties identifying the indigent. An action research was implemented to test the hypothesis that a community-based process for selecting beneficiaries of user-fee exemptions in an African environment of BI organisation is feasible. Methods: This study was carried out in 10 primary health centres (CSPS) in Burkina Faso. Village selection committees (VSC) made lists of those worst-off, and the lists were validated by village chiefs, mayors, and health committees (COGES). A process evaluation was implemented using documentation analysis, accounting calculation, focus groups and in-depth interviews. Results: The 124 VSCs selected 566 persons. The 10 COGESs retained 269 persons (48%), ie 2.81 per 1000 inhabitants. Except for one CSPS, the annual profits from the user fee schemes could support on average six times more indigents than the mean number selected by the VSCs. Conclusions: In the rural African context, villagers are capable of selecting those who should be exempted from user fees according to their own perspective. Thanks to the BI, health centres have a certain financial capacity to take care of the indigent. In a community-based targeting approach using endogenous resources generated from BI profits, local perceptions of the health centres’ financial viability, coupled with the hierarchical social context, led to a very restrictive selection of candidates for exemption.