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The Removal of Health User Fees in Africa – Key Lessons from Sierra Leone

The Removal of Health User Fees in Africa – Key Lessons from Sierra Leone. One World Link Leamington Spa 12 th January 2011 Rob Yates Senior Health Adviser Department for International Development. Goderich Health Centre, Sierra Leone 3 p.m. Monday 26 April 2010.

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The Removal of Health User Fees in Africa – Key Lessons from Sierra Leone

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  1. The Removal of Health User Fees in Africa – Key Lessons from Sierra Leone One World Link Leamington Spa 12th January 2011 Rob Yates Senior Health Adviser Department for International Development

  2. Goderich Health Centre, Sierra Leone 3 p.m. Monday 26 April 2010

  3. Goderich Health Centre, Sierra Leone 3 p.m. Thursday 29 April 2010

  4. Children’s Hospital Freetown, Sierra Leone 8 a.m. Tuesday 27 April 2010

  5. Sierra Leone: why people don’t use health services

  6. Theoretical Rationale for User Fees • User charges at government facilities should raise substantial revenue to fund services • User charges should improve access of the poor to health services through X-subsidies • User charges should make the delivery of government health services more efficient World Bank Health Financing 1987 • Reduce frivolous use of services • “People only value services if they have to pay for them”

  7. The record of user fees • Ineffective: Raised little revenue – typically 5% of health sector budget • Inefficient: due to high administrative costs and unutilised capacity caused by low levels of demand • Inequitable: Reduced access for the poor - No cross subsidisation of rural services - Exemption schemes do not work

  8. Source: Yates R. Universal health care and the removal of user fees. The Lancet 2009; 373: 2078-81

  9. Source: Millennium Village Project Rwanda

  10. Recent Research Evidence • James et al in BMJ (2005): removal fees could prevent 233,000 child deaths in 20 African Countries • Kremer and Miguel (2004): 10c charge reduced demand by 80% for deworming medicine for children • Cohen and Dupas (2007) : 75c charge reduced demand by 75% for insecticide treated bed nets amongst pregnant women in Kenya • http://www.povertyactionlab.org/policy-lessons/health/pricing-health-products

  11. ITN Coverage in Kenya Free Bed Net Distribution for Children

  12. The Rapid Removal of Health User Fees in Africa since 2000 Niger free for <5s and deliveries 2006 Sudan free services for <5s and c-sections Feb 2008 Senegal free deliveries 2006 Liberia all services free Feb 2007 Kenya free deliveries Oct 07 Ghana free services for children and pregnant women May 08 Uganda all services free Mar 01 Burundi free for <5s and deliveries Aug 06 Zambia free services in rural districts Apr 06 Countries with free services pre 2000 Lesotho free services at primary level Jan 08 Countries introducing free services since 2000 Source: Yates R. Universal health care and the removal of user fees. The Lancet 2009; 373: 2078-81

  13. Global Consensus on Maternal Newborn and Child Health 5 point checklist of policies and prioritised actions including: “Removing barriers to access, with services for women and children being free at the point of use where countries choose” http://www.who.int/pmnch/topics/part_publications/2009_mnchconsensus/en/

  14. DFID Position • The Government believe that nobody should die or suffer ill health because they are too poor to afford treatment. This is why we support international efforts to achieve universal coverage of basic health services. Evidence shows that removing financial barriers increases poor women's uptake of reproductive, maternal and newborn health services. Where appropriate, DFID will provide technical and financial support to countries that wish to remove fees at the point of use of services and replace them with more equitable health financing systems. This includes making essential health services free at the point of use, and supporting the poorest women to meet the indirect costs of health care by piloting innovative approaches like cash transfer programmes http://www.theyworkforyou.com/wrans/?id=2010-12-21a.32347.h&s=speaker%3A10670

  15. Fee removal should be part of wider reforms • There are more barriers than removing fees • Sustainability: LICs and donors must increase levels of public spending on health • Improve performance of public financing – effective, efficient and equitable • Need genuine political commitment to oversee policy reforms • Improve mechanisms for populations to hold governments and donors to account

  16. Sierra Leone’s Extensive Reforms • Cleaned entire health payroll in two months • Removed ghost workers and used savings to recruit 1000 new health workers • Health worker salaries increased from 2 to 5 times • Procured over £ 5 million of essential drugs • Reorganised drug supply system • Massive communications campaign • Whole process led by the President http://www.ministerial-leadership.org/blog/6-months-later-sierra-leone%E2%80%99s-president-koroma-free-health-care

  17. Thank you!

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