Operational Research on Health care for the poorest

1. Operational Research onHealth care for the poorest Mauritania Ministry of Health and Social Affairs GTZ –Basic Health Care Project

2. Objectives • Description of our strategy • General situation • The Challenges • Contextual Opportunities • Implementation • Results and lesssons learned

3. General Situation The country : Islamic Republic of Mauritania Area: 1.030.700 sq km Population: 2.912.584 (July 2003) Mostly living in Nouakchott, Nouadhibou and the southern Senegal river area Climate: desert, constantly hot, dry and dusty Economy: agriculture and livestock iron rich fishing area oil  2005?

4. General Situation Development policy in the Islamic Republic of Mauritania In general Since 2001 Poverty Reduction Strategy Paper Consistent donor support through the HIPC initiative • In the health sector  Midterm Budgetary Framework 2002 – 2004 • 3 main additional objectives: • TO IMPROVE THE HEALTH INDICATORS OF THE POPULATION AND MORE SPECIFICALLY THOSE OF THE POOREST GROUPS OF SOCIETY. • TO LIMIT THE IMPACT OF HEALTH EXPENSES ON THE HOUSEHOLD BUDGETS OF THE POOREST. • TO IMPROVE THE PARTICIPATION OF THE POOR IN THE MANAGEMENT OF THEIR HEALTH SERVICES.

5. General Situation ORGANIGRAMME Responsibilities • Develop policies • Develop laws • Coordinate and monitor activities Target groups • Socially deprived • Handicapped persons • Children with problems Tools Needy Certificate (local government) Ministry of Health and Social Affairs Direction for Sanitary Protection Direction for Social Action Regional Direction for Health and Social Promotion Regional Service for Social Action Regional Hospital Health Centre • Responsibilities • Social support of the poorest • Support to the local government social services Health Post

6. 46,3% 31,4% Poor Extreme Poor Poverty in Mauritania Profile for 2000

7. The Poor and the Health services • There is a part of the population that is very poor, badly defined and therefore badly served by public health services. Health care not accessible • There is no efficient strategy defined by the health and social affairs department to take care of these people • Only an approach by social groups (handicapped, …) or a pragmatic, case by case approach of the health staff

8. The Challenges • To offer the poorest of the poor access to quality health services. • Key questions: • What is “Being poor”? • Who determines who is poor? • How to pay for their health care?

9. Our Strategy • Loss of traditional social relations • Loss of existing, traditional social backup • Insufficient rural production • Inefficiency of the new institutions to deal with the poor POVERTY, EXTREME POVERTY Inefficiency of the new institutions to deal with the poor Problem of access to care for the ‘needy’ Efficient social strategy (acceptable, everlasting) Absence of an efficient social strategy Concept Context Context Concept

10. Poverty Health Protection of health and assistance to ill people Solidarity between Muslims  redistribution of wealth from the rich to the poor Zaakat = solidarity tax : 2,4% The contextual opportunities (local actors) 1. Islam  religion of the entire population and source of the national law system Islam General principle: « It is obligatory to preserve his own health and the health of others » One of the pillars of Islam Alms, charity = obligatory for each Muslim whose belonging are more important than a certain level. Wealth has been accorded by Allah and does not belong to the Muslim. • Attitude of the Muslim towards ill people recommended by the texts: • Support and assistance • Act against stigmatisation (wrongful act) • Compassion • Material support • moral support

11.  The political will to improve living conditions of the poor  An important increase of the budget (x 6) contextual opportunities 2. The state Decentralisation: Decision and use of resources at the peripheral level 

12. Contextual opportunities 3. Local government or community • Democratisation of the country  emergency of social society • Local government has a responsibility to support the ‘needy’ and the health system • Specified in the official government declarations and in the budgetary allocations.

13. Building alliances • Looking for a consensual definition • Participative approach to develop and write the project • Setup of a Coordination Committee regrouping the ministry of interior, the ministry of health and social affairs, the secretary of state for women affairs, the commissioner for human rights and the fight against poverty and religious organisations (rabita, …).

14. Implementation The place 17 pilot sites, around the health structures in the regions of Hodh El Gharbi and Hodh Echargui. population : 84.183 habitant • Regional hospital: 2 • Health centre: 5 • Health Post: 12 Start of the processus: 1/ 2003 Start of the assistance: 6/ 2003

15. Implementation Definition of the ‘needy’ CONSENSUAL AND CONTEXTUAL Definition (consultant + seminar): « Needy is the situation in which a person, although he may be able to satisfy an elementary need for food, is potentially not able to pay for essential medical care» An operational form of the definition :«Needy is the situation in which a person is not able to satisfy an elementary need for food (Sed Ramagh), … » Base : notion ‘FOOD’:  criterion used in some modern definitions of poverty  criterion used by the Islam case law (Figh)

16. Implementation Identification: PROXIMITY AND REPRESENTATIVITY A. Setup of the committees: • Composition: • Choice of the members : • independent of the health services • only directive  to involve religious leaders and members of local government • Different compositions : • members of traditional and religious organs (imam, faghih, village chief, …) • community organisations (local government, health committees, …) • staff of the health infrastructures • Tasks: • to identify the ‘needy’ on the basis of the consensual definition • to collect resources at the local level to pay for health care for the ‘needy’ • to manage these resources •  Interaction with the Regional Direction for Health and Social Affairs: * Regional Service for Social Action: support and control * Responsible of the health services: close collaboration

17. Implementation Identification: B. Elaboration of the lists of the ‘needy’ (by the committees) • Who? • every adult person corresponding to the definition and not taken in charge by a third person • every child below 18 depending on those adults • How? • proposition by a committee member • decision by whole the committee • establishment of the lists • validation by the Regional Service for Social Action  control of the lists • door-to-door survey of 10% of the people on the lists  >80% should be conform to the definition • Recommendations to the Identification committee

18. Implementation C. ‘Needy’ certificate Signed by the president and signed by the Regional Service for Social Action • Nominative • The only justification for free access to health care Identification:

19. Implementation Financial resources : Regional Hospital and : • 10% of the hospital State budget Health Centre • 10% of health centre State budget • Budget of the local government - as much as they can contribute • Contribution of the population 1. « Zaakat , Sadagha…» - Fatwa 2. 10% of the Cost recovery benefice Health Posts: • Budget of the local government, except in certain posts to test the influence of external (state!) funds • Contribution of the population (Zaakat + cost recovery + private)

20. Implementation Care package : • Care in the public health services (from the health post up to Nouakchott) • Medicines bought in private pharmacies, only if not available in the public system • Transport to and from the reference level for the needy and one accompanist On the basis of a contract The communities commit themselves to pay for care at the level of the health post (deter communities from inflating the beneficiaries lists) The state budget compensates for additional costs at the referral level.

21. Implementation • Circuit of assistance to the ‘needy’ patient Two options : • With card  care • Without card: - no emergency referred to identification committee - emergency supported by the facilities’ own funds

22. Results A. Identification Population ‘needy’ : 8 516 persons Percentage ‘needy’ : 11 % (much below the figure of 31,4%) Beneficiaries (3 month) : 996 ‘needy’ RH : 45 Health Centre :524 Health Post :427 0,5 contact/needy/ year Composition of the ‘needy’ population

23. Results Contributions/ source/month 300 ouguiya = US$1

24. Results Expenses

25. Lessons learned Muslim society  The Koran and the Islamic case law contain solidarity mechanisms aiming at the redistribution of wealth in favour of the ‘needy’:Zaakat, wagf, charity, religious legacy, … Taking care of the ‘needy’ is not expensive  average cost is at 1004 UM which is about 3 EURO

26. Lessons learned Communities are capable of managing their ‘needy’ if they are given the necessary responsibility and support  empowerment Managing things at the local level allowed for a more acceptable identification and a more transparent management  social control

27. Perspectives Monitor and evaluate the pilot experimentReinforce collaboration with the commissioner for human rights and the fight against poverty to find solutions for border-line cases Progressive extension of the model in the other regions of the countryDocument the research  scientific backup

28. Mauritania Ministry of Health and Social Affairs GTZ –Basic Health Care Project

29. Results: circuit of the Needy Patient WITHCARD AND/OR MEDICINES OR CARE ENROLLMENT DIAGNOSIS REFERRAL «  NEEDY » TAKEN IN CHARGE WRITTEN PROMISE TO PAY REIMBURSEMENT EMERGENCY REFERRAL TO A COMMITTEE SESSION TO DECIDE IF REALLY ‘NEEDY’ DECLARES TO BE ‘NEEDY’ TAKEN IN CHARGE WITHOUTCARD NOT TAKEN IN CHARGE ON THE ‘NEEDY’-MONEY NO EMERGENCY