HOW TO IMPROVE ACCESS TO REHABILITATION SERVICES FOR POOR PERSONS IN AFRICA?

1. HOW TO IMPROVE ACCESS TO REHABILITATION SERVICES FOR POOR PERSONS IN AFRICA? EVALUATION OF THREE REHABILITATION EQUITY FUNDS SET UP IN MALI, RWANDA AND TOGO. Rozenn Botokro – West Africa Rehabilitation Advisor – Amman - Jordania - December 2009

2. Context and actors analysis • Mali 173/177 ; Rwanda 161/177 ; Togo 152 • Persons with disabilities are “Among the poorest of the Poor” (Elwan) • 15 to 20 per cent of the poor in developing countries (Helander) • no incomes and no insurance • less opportunities of support

3. Context and actors analysis • Low attendance of the rehabilitation centres • Capacity of the centres to take on more activity • No free care, no individual cash transfers by the States • Very low willingness and capacity (Mali, Togo), some willingness and low capacity (Rwanda) of the State

4. Handicap International • is working in Mali, Rwanda and Togo for years in the field of rehabilitation • These 3 Rehab Equity Funds (or HEF) are little parts within three different rehabilitation projects • designed by different people at different times, with different funding sources = no interaction between them.

5. Equity funds • One goal : Paying the provider on the poorest’s behalf • Two principles (Noirhomme & al.): - specific fund allocated to pay selected services to deliver quality care at given rate - Management of the fund entrusted to an independant « purchasing body » or to another institution to which the third-party payer delegates this role

6. Management USAGERS DES SERVICES (USERS) • To identify users, to assess poverty, to monitor beneficiaries TIERS-PAYANT INDEPENDANT PURCHASING BODY PRESTATAIRES (PROVIDERS) • to monitor the quality and cost of the care provided • To make • all necessary refund

7. Beneficiaries • Over 3 years, the Rwanda HEF has helped provide rehabilitation care to 819 people, against 591 for Mali and 308 for Togo. • Women represent the majority of beneficiaries in Rwanda (54%) and Mali (60%). However, they account for only 45% of beneficiaries in Togo. • The average age of beneficiaries is 25 years in Rwanda, 31 years in Mali and 30 years in Togo.

8. Functioning

9. Responsibilities

10. Cost calculation • only costs covered by HI • to answer the following question: how much does it costs the facilitating organization to launch and implement an HEF? • Expenses required for the setting up and/or operation of the fund have been taken into account.

11. Cost calculation • overall cost varies greatly : 229,000 euros for Mali, 186,000 euros for Rwanda and 120,000 euros for Togo. • average rehabilitation cost per beneficiary is similar from one country to another: 140 euros for Rwanda, 175 euros for Mali, and 193 for Togo • more differences in the average overall cost per beneficiary (which includes the costs of rehabilitation as well as the operating costs).

12. Cost calculation

13. Effects on the beneficiaries • HEFs have undoubtedly allowed very poor people with disabilities to have access to rehabilitation services which were previously inaccessible to them, thus enhancing their autonomy.

14. Structural effects • HEFs enable rehabilitation services to develop their activity • HEFs could create jobs in health facilities, but also in private workshops where crutches and tricycles are produced. - HEFs strengthen the credibility of DPO’s vis-à-vis the State and the community

15. Structural effects • HEFs prove to the State the importance of a strong response to the needs of the poorest Persons with Disabilities, and show that it is quite possible to improve their social inclusion. • and encourage the State to create rehabilitation services and train professionals.

16. more generallyeffects • HEFs make the different rehabilitation stakeholders collaborate more (Rehab services, hospitals, social services, DPO’s, ministries...) • HEFs popularize rehabilitation services among in communities.

17. more generallyeffects • HEFs educate everyone on the right to rehabilitation. • HEFs could create jobs in health facilities, but also in private workshops where crutches and tricycles are produced.

18. The advantages of HEFs over other methods of financing FR care • In countries which have opted for a cost recovery policy : three options: mutual insurance companies (public or private), HEFs, or exemption Exemption • Full exemption requires strong political will and funds • exemption would be in strong contradiction with the principle of cost recovery.

19. mutual insurance system It seems completely impracticable for rehab needs : • the sums required are higher than for basic care, whereas Persons with Disabilities are poorer than average, • the needs of these people are ineluctable. • However, no physically disabled person is exempt from rehabilitation expenses (particularly as physical therapy can take a long time, and devices have to be maintained and renewed regularly).

20. Sustainability, the main challenge • State : funded by the government through taxes, or by public national insurance companies which accept to devote a portion of the subscriptions of their members to the HEF, which would however be in violation of their sustainability principle. • Another option : "basket-funds" credited by different institutions. two constraints: • To regularly look for new contributors to counter the possible withdrawal of those already involved. • It requires that the contributors agree on who will be responsible for managing the HEF.

21. Recommendations What not to do in order to make an HEF successful: • Entrust the management to a service provider • Use selection procedures that are too complicated • Fund micro credits or IGAs using an HEF • Determine contributions on the basis of the total cost of the care • Not apply the same rules to all

22. What to do to contribute to the success of an HEF • Entrust the management to national institutions established locally right from the beginning • Target beneficiaries through an effective identification system • Conduct rigorous surveys with beneficiaries • Systematize the payment of a contribution

23. What to do to contribute to the success of an HEF • Better take into account the specific case of growing children • Better take into account patients who need physical therapy only • Reduce the time between patient identification and device delivery • Continue to support FR services as regards the biggest expenses

24. Key points : • The existence of donor funding • The presence of a driving agent • Clear separation of roles • Appropriate identification techniques • Holistic consideration of barriers to utilization of services

25. Conclusion