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Removal of User fees in public health facilities: Challenges in design and implementation. Presenter : Walimbwa Aliyi Senior Health Planner, Ministry of Health Uganda (2-4/10/ 2010. Presentation Outline. Background. User fees reform, its abolition & challenges in implementation.
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Removal of User fees in public health facilities: Challenges in design and implementation Presenter : Walimbwa Aliyi Senior Health Planner, Ministry of Health Uganda (2-4/10/ 2010
Presentation Outline • Background. • User fees reform, its abolition & challenges in implementation. • Trends in health care financing. • Lessons learned & way forward on increasing access to health care.
Background • Total population 32 million, with annual growth rate of 3.2%. • GDP per capita U$ 450. • Population below poverty level is 23% (<1US $ a day). • Physical access to health care 72%. • High burden of communicable diseases (Malaria, HIV/AIDS, respiratory infections, diarrhea diseases but also the none-communicable diseases are on the rise).
National health System (NHS) • The NHS comprises of 2National Teaching and 13 Regional Referral Hospitals that directly report to MOH. • District & health sub-district levels have 56 General hospitals & 2,562 health centre II to IV that report to Local Governments. • In addition to the public, there are Private Not-For-Profit (PNFP), Private For Profit (PFP) and Traditional Complementary Medicine Practioners (TCMP)
User fees reform • User fees were gradually introduced in public health facilities starting in 1990. • In March 2001, the president on a political campaign rally issued a directive to the Ministry of Health to abolish user fees in PHF except in grade A of hospitals. • He cited complaints and reports on the campaign trail that around 50% of those in who needed services were denied access to health services (Berman et al. 2001). • Most implementers were taken by surprise. A presidents directive had to be implemented. No discussions or advice.
Trends in health services utilisation • Improved immunisation coverage & high OPD attendances with the poor benefiting most (Deininger and Mpuga 2004, & Nabyonga et al 2005, Health Sector Strategic Plan II). • Government compensated revenue lost (US$ 5.5 million), PHC funding increased (33 % to 54% of the MOH budget), medicines budget rose from US$ 0.8 to 1.2 per capita, additional 30-50% of PHC budget was put for essential medicines and health supplies. • Increased funding to PNFP health facilities from UG SHS 38 billion in 2001 to 60 in 2002. • Health Worker salaries were enhanced by 60% & staffing levels (42%-66% by 2003) (Nabyonga et al, 2005).
Implementation of the reform • Given the importance of the reform, MOH/WHO carried out studies to monitor progress. • Continuously monitored health indicators (Health Sector Strategic Plans, Annual & Mid-Term Reviews, Demographic Health Surveys, Civil Society reports & Service Provision Assessments. • Strengthened HMIS & Operational research. • Disciplinary action on illegal/under-table charges.
Challenges in implementing user fee reform • Implementation and transition was not smooth due to limited capacity of the health system to cope with policy change. • Inadequate infrastructure & government funding, staff morale Vs workload, • Increasingly high out-of-pocket payments & perceived poor quality services.
Challenges of implementing user fee reform Not very sustained benefits to ensure financial access to quality health care. • High out-of-pocket payments (up to 9-10% of household consumption expenditure). • About 28% of sampled HHs in 2006 experienced catastrophic expenditure (UNHS 2006). • Per capita health expenditure of US$ 33 Vs US$ 41.2 required for UNMHCP. • Per capita funding for medicines including vaccines =US$ 5.86 against budget provisions of only US$ 0.93 (AHSPR 2009). • Only 56% of health facilities did not experience stock-outs of key indicator medicines.
Lessons learned & conclusions • Improper implementation of user fees can be catastrophic. Indeed financial access had become a barrier. • Reforms with good intentions may fall short of expectations when quality services are not availed and sustained. • Consultative approach in health financing reforms is desirable, to improve where it hurts and sustain where benefits are real to patients and providers. • Need for continuous monitoring and re-evaluation of reforms. Abolition later turned public to either under- table payments or greater use of the private sector including traditional practitioners. • Pre-payment schemes a better option but not yet understood or implemented by the greater population.
Lessons Learned • When awareness is raised and the Health System is strengthen through availing more trained, better paid health workers; better medicines and health supplies stocks; and other quality values, utilization improves. • Abolition of fees helped the lower quintiles to access services.
Way forward • Have a health sector financing strategy by 2011 that address financial access. • Adopt NHI policy (Social & Community Health Insurance). • Design & have a NHIS operational by 2011 /2012 financial year. • Provision of national user fees guidelines.
Way forward • Salary enhancement that can tackle the basics of living in a society and not mere nominal increments. • Health systems strengthening (Infrastructure improvement, provision of essential medicines an health supplies, good leadership & Management of the sector facilities. • Use NHSSIP to lobby for progressive increase in government funding towards the Abuja declaration. • Strengthening SWAP & use of priority disease projects to strengthen systems. • Efficiency in resource allocation and utilisation.
