Fee exemption policies for maternal health services

1. Fee exemption policies for maternal health services A Review of 11 African countries Benin, Burkina Faso, Burundi, Ghana, Mali, Morocco, Niger, Nigeria, Kenya, Senegal, Sierra Leone Fabienne Richard, ITM Antwerp & Matthieu Antony, CERDI Clermont-Ferrand

2. Purpose of the review • 1st objective:Compare the benefits package covered by the fee exemption policies across the three dimensions of universal coverage: • The breadth (percentage of population covered ) • The depth (range of services covered) • The height (proportion of coveredcosts) 2

3. The three dimensions of universalcoverage: Exemption policy coverage Couverture de la politique d’exemption 3

4. Purpose of the review (part 2) • 2nd objective : Compare the funding modalities of these targeted policies • Reimbursement system for health facilities • Estimation of the budget envelope at national level • Forecast versus disbursed budget • … 4

5. Methodology • Questionnaire developed by the FEM Health team with validation by the workshop organizing committee (2 parts: content and funding) • Pre-test in Burkina Faso • Sent to all countries that participated at the workshop by email to a key informant at central level • Follow-up by telephone and email • Comparative analysis of 11 sheets 5

6. Result of part 1

7. Chronology of the policies introduction Kenya Phase 1 Senegal Phase 2 Nigeria Phase 1 Ghana Phase 2 Burundi Child under 5, Delivery, C-.Section Kenya Phase 2 Burundi Pregnancy-related diseases Senegal Phase 1 Niger Ghana Phase 3 Nigeria Phase 2 Ghana Phase 1 Mali Burkina Faso C-section Burkina Faso Delivery Morocco Benin Sierra Leone Kenya Phase 3 2004 2005 2006 2007 2008 2009 2010 2011 7

8. Benin Mali Senegal Burkina Faso Burundi Ghana Kenya (according to income) Morocco Niger Nigeria Sierra Leone (+ breastfeeding women) Who is covered? 8

9. Kenya: some regions only Nigeria: some regions only Senegal: Dakar not covered Benin Burkina Faso Burundi Ghana Morocco Mali Niger Sierra Leone In what area of the country? Targeted regions Everywhere 9

10. In which hospitals? KenyaGhanaNigeria* * except at tertiary level hospitals Benin Burkina Faso Burundi 10

11. Which services are covered? Covered by another exemption or subsidy policy DC = Directs obstetric Complications Hyster= hysterectomy Ect.P = Ectopic Pregnancy +++ ++ + 11

12. Costs covered by the fee exemption or subsidy policies * Emergency Medical Services (EMS) rural in Morocco in isolated areas 12

13. Proportion of covered costs • The majority of countries cover 100% of the costs of target services under the policy • 2 countries require some co-pay for direct costs of targeted services • Burkina Faso (80% of directs costs) • Kenya (ticket between 1 to 2 $) 13

14. System set up to comply with different referral levels • Burkina Faso: • Delivery reimbursement = 80% in health centre and district hospitals • Reimbursement = 60% in regional and national hospitals • Morocco: • Exemption policy applied in UHC only for referred women 14

15. A multitude of targeted exemption policies Most countries also have a national policy to cover the indigent, but they are not always implemented in practice. 15

16. Synthesis • The minimum in common in the 11 countries is the management of Caesarean section • Other obstetric complications: • 2 countries do not cover other obstetric complications during labour and interventions other than Caesarean section • 4 countries do not cover postnatal complications • Transport costs: • Only Morocco covers transport from home to the health facility through rural EMS (in 24 provinces with difficult access) • Only 5 of 11 countries cover the costs of transportation between health facilities • Targeting the poorest: • The majority of policies apply to the entire population of pregnant women regardless of their income except for Kenya (policy targets poor pregnant women). 16

17. Complexity and variety of strategies • There is no single common strategy for fee exemption policies for maternal and child health care = no cut and paste, each country has a different system. • The majority of these policies do not cover all maternal and neonatal care so it is always partially paid for by the patient/family. • Exemption policies for maternal and neonatal care are not unique: • Several other exemption policies target other diseases or populations. • Several countries are simultaneously developing a national health insurance system • Complex architecture for fee exemption policies: • Do health personnel see their place in it? Do populations? • Is there coordination among these different targeted exemption policies? • Is there coordination among these fee exemption policies and institutional framework being set up for health insurance ? 17

18. Targeted exemption policies :can we do better? Pregnant womenUnder fiveElderly… C-section & DeliveriesTB, Malaria, HIVFamily Planning Health centre Hospitals, 1st, 2nd, 3rd level?