Health Care Access for the Poor in Ethiopia

Health Care Access for the Poorin Ethiopia AbduljelilReshad, FMOH, EthiopiaDirector of Resource Mobilization November 2/2010Dakar, Senegal

Outline of the Presentation • Policy Framework • HCF Strategy • Components of Reform • The Waiver System • The Exemption System • Health Insurance Initiatives

Policy Framework • Health Policy & strategy Developed in 1993 • Emphasizes the fulfillment of the needs of the less privileged rural population that constitutes about 83% of the total population through: • Democratization and decentralization of the health system; • Development of the preventive and promotive components of the health service; • Ensuring accessibility of health care by all population; • Inter-sectoral/NGO/Private sector collaboration • National self- reliance in health development by mobilizing and efficiently utilizing internal and external resources.

Policycont…. • A 20 year HSDP launched (1998-2018) with the basic objective of improving the coverage and quality of heath services • HCF is one among 7 components of HSDP

HCF Strategy • Strategy adopted in 1998 • The strategy focuses on: • Increasing available resources • Improving their allocation • Increasing resource utilization • Ensuring equitable distribution

HCFStrategycont…. Rationale • Serious decline in health care delivery • Government spending not sufficient to finance health • Need to assess alternative methods of financing

Components of Reform • Facility revenue retention and utilization • Facility governance • Fee waiver and exemption • Out sourcing and private wing • 2nd generation reforms: • Social Health Insurance & • Community based Health Insurance

Components cont…. • Legal frameworks issued at federal and regional levels • Legal frameworks: • Proclamations • Regulations • Directives • Implementation Manuals

Components cont…. • Contents of legal frameworks/strategy • Revenue Retention and Utilization • Fee Waiver and Exemption Systems • Hospital and Health Centers Management Boards • Outsourcing and Private Wings • Gradually to start health insurance schemes

Fee Waiver System • A fee waiver is a right conferred to a household or individual that entitles the household/the individual to obtain health services in certain health facilities at no direct charge • Introduced nearly 50 years ago The practice before HCF: • disorganized fee waiver system • health facilities are financing fee waiver • high leakage and under coverage in the system • Hence need for targeting/identify beneficiaries

Fee Waiver cont…. Purposes: • To protect the poor i.e. equity concern • To ensure sustainability of financing • Impact on quality

Fee Waiver cont…. Beneficiaries of the System • Households/Individuals who cannot afford to pay for health services and thus are provided waiver certificates from Woreda administration offices. • Street children and homeless citizens who can provide evidence from the office of labor and social affairs. • Displaced persons when they provide evidence from Kebele administration, and disaster prevention and preparedness bureau • Persons receiving 24 hrs emergency care provided by health institutions, who can not afford to pay for the service, and people with no third party accountable for them.

Fee Waiver cont…. Identification Procedures • The Kebele Administration sensitizes the community concerning the availability of such services and procedures to obtain the services • Community in each Got for rural and each sub-kebele in urban identifies potential beneficiary households • Kebeleadministration will compile list of proposed beneficiaries and present it to the kebele council for review and approval

Fee Waiver cont…. Identification Procedures • The Kebele council will review the proposed list to prioritize the beneficiaries selected by the Gotsin accordance with the level of poverty of potential beneficiary households. • Each Kebele submits the list of agreed potential beneficiaries to Woreda administration • The Woreda administration shall review the list of beneficiaries sent by Kebeles and approve the final beneficiaries

Fee Waiver cont…. Selection Criteria • Rural areas: • Size of land holding • Number of dependents • Number of livestock holding • Level of harvest • Ability to work and earn income • Use of other objective criteria in the locality to identify the poor.

Fee Waiver cont…. • Urban areas: • Homeless, and lives on street • Orphaned children who have no financial support from relatives or no adequate pensions from their parents • Households earning less than minimum wage • Households depending on petty trades who are unable to meet their daily subsistence • Household size

Fee Waiver cont…. Responsibilities of Various Organs & Government Offices • GotCommunity • Identifies persons eligible for waiver in the community and submits the same to the Kebele administration. • Responsibilities of Kebele Administration • Sensitization • Facilitate the identification of eligible beneficiaries by Got/Sub-Kebele community. • Compiling list of proposed beneficiaries • Submitting the finalized list of eligible beneficiaries to the Woredaadministration

Fee Waiver cont…. • Responsibilities of Woreda/City Administration • Sensitization • Compile finalized list of eligible beneficiaries received from Kebeles, WOLSA, and DPPC • Review and endorse the list of beneficiaries eligible for waiver • Allocate the amount of budget needed for reimbursement to health facilities. • Enter into an agreement with health facilities to provide waived services and the subsequent reimbursement • Issue fee waiver certificate for eligible households/ persons • Reimburse facilities for waived services provided based on the agreement with health facilities

Fee Waiver cont…. Implementation Experience: Example from one Region • 1.4 million people were identified as eligible to use fee- waived services by Woreda Administrations. • All Woredas have started the implementation of the fee waiver system • On average 25,000 to 30,000 Birrallocated per Woreda • Most health centers are getting reimbursements timely • The progress is encouraging, there are concerns related to the size of those identified as fee waiver beneficiaries given the high poverty level in the region.

Fee Waiver cont…. Challenges in Implementing the Waiver System • Lack of awareness by both service providers and users • Frequent turnover of the Woreda officials • Shortage of budget allocated by the government • Identifying the poor is a difficult task • So many competing tasks & tight schedule other than implementing waiver system by woreda officials • Disorganized fee waiver system • The net costs of waivers (in terms resources used and revenue forgone) are never reimbursed • Lack of coordinated efforts by all actors

Exemption System • One form to improve access to service for the poor • Refer to those health services that are rendered free of charge to all irrespective of level of income • Objectives: • Services of public health nature that widely affects the general public • Improving the health seeking behavior of the society

Exemption System cont…. • List of currently exempted services provided free of charge irrespective of the ability to pay: • Diagnosis, treatment and follow-up of TB • Prenatal, delivery and postnatal services in PHC • Family planning services • Immunization of mothers and children • VCT • Leprosy management • Epidemic follow-up and control • Fistula management

Exemption System cont…. • The health office and health facilities have the responsibility to create awareness of the exempted health services and to encourage the community by posting, broadcasting in the mass medias and/or advertising • The health facilities shall finance the costs of exempted services from the appropriated government budget or donations

Health Insurance Initiatives • Why Health Insurance? • Enables to utilize health services without requirement of payment at the time of service • Promotes equity & helps to avoid catastrophic health care expenditures • It pools risk and create cross-subsidization between the poor & rich on one hand and the healthy and relatively sick on the other hand. • Mobilizes additional resources for the health sector • Improves health service utilization and hence achieve improved health status

Health Insurance Initiatives • A strategy on health Insurance has been developed in 2008 • The strategy stipulates the types of health insurance to be implemented in the country i.e. SHI and CBHI • Provided directions on the basic features of SHI and CBHI such as: • Membership • Premium/Contribution • Benefit Package • Service Providers • Provider Payment Mechanisms • Institutional Arrangements

Health Insurance Initiatives Implementation Approaches: • SHI • Designed for formal sector employees and to be financed by payroll contributions both from the employees and employers • Proclamation endorsed recently by the federal parliament and implementation will begin within a year time

Health Insurance Initiatives • CBHI • Improve access to health services for the poor • Designed for the population engaged in informal sector and financed by contributions from members and subsidy from the government • Will be pilot tested for two years and scaled up based on the results of pilots • Pilot implementation will start from January 2011

Acknowledgment • USAID: for the Financial and Technical support to realize the health care financing reform in Ethiopia • All DPs • Organizers of this important Experience sharing forum

Thank You for Your Attention

Health Care Access for the Poor in Ethiopia