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									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
                                                          MDGs- the importance of consuming services
                                              Under 5 Mortality Rate vs Total Outpatient Utilisation In Selected African
                                                                              Countries
                                        250
Under 5 mortality rate (per 1000 live




                                                                  Somalia
                                                     DRC
                                                                         Rwanda
                                        200
                                                  Sierra Leone          Burkina Faso      Zambia
                                                             Ethiopia                               Mozambique
                                                                         Benin
                                        150                                                                       Malawi
              births)




                                                                                                   Uganda                    Tanzania
                                                                         Ghana
                                        100                                                                 Botswana
                                                                                                                                 Sudan

                                         50


                                          0
                                              0            0.2          0.4         0.6            0.8        1            1.2           1.4
                                                                         Outpatient visits per person per year
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
Children’s Hospital Freetown, Sierra Leone
8 a.m. Tuesday 27 April 2010
                                             5
6
7
Sierra Leone: why people don’t use health services




                                                 8
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”
                                                          9
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


                                                    10
                        The Sudden and Sustained Impact of Abolishing User Fees
60000
                     Total Monthly Outpatient Attendances in Kisoro District 1998-2007
                                                                                         Utilisation Rate
50000                                                                                    1.6 visits per
                                                                                         person per year
40000

                                   User fees abolished
30000


20000
                                                                                     200% increase
10000


    0
        Jan    Jan       Jan       Jan       Jan         Jan      Jan       Jan          Jan       Jan
         98     99        00        01        02          03       04        05           06        07
                      Outpatient attendances                   12 month moving average

 Source: Yates R. Universal health care and the removal of user fees. The Lancet 2009; 373: 2078-81
                  New Monthly Outpatient Attendances in 2 Neighbouring Hospitals
6000
                                  GoU User fees abolished
5000

4000

3000

                                         PNFP reduces fees
2000

1000

     0
              9




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                  Mutolere PNFP                             Kisoro Government
                  12 month moving average                   12 month moving average
           Utilisation rate (visits per year ) by socio -economic category

1 .4

1 .2

  1

0 .8

0 .6

0 .4

0 .2

  0
       J   F   M   A      M   J   J    A   S   O   N   D   J   F M     A   M     J   J   A     S   O   N    D

                              2001                                               2002



           Po o r e s t               Less poor                B e tte r o f f               R ic h e s t
                       Abolition of Health Care User Fees - Evidence from DRC
                        Health Care Utilisation In Goma By Children Under 5
                             Measured In Visits Per 100 Children Per Year

500
450
                     Fees Abolished
400
Eruption
350
300                                                                start low fee
250
200
150
100
 50
  0
  14/01/2002   24/01/2002   03/02/2002   13/02/2002   23/02/2002      05/03/2002   15/03/2002   25/03/2002


                               Utilisation by under 5s         7 day moving average                          14
                       The importance of removing financial barriers in Rwanda-
                       Outpatient attendances at 2 neighbouring health centres
5000
4500                                                                     User fees removed

4000
3500
3000                                                                                                      Utilisation rate of 1.9
                                                                                                          visits per person per
2500                                                                                                      year = 3.2 times the
2000                                                                                                      national average

1500
1000
 500
   0
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  Source: Millennium
  Village Project Rwanda                                   Mwogo         Mayange                                          15
      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
                                               16
       ITN Coverage in Kenya

      Free Bed Net Distribution for Children
80%


60%
                                          Most
                                          poor
40%
                                          Least
                                          poor
20%


0%
      2004      2005       2006
                                               18
 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
                                        In Burundi in 2005 around one in five babies were born in health units, now the
                                                     majority are. How has the Government achieved this?

                                   60
                                                                                                      146% increase since 2005
% of babies born in health units




                                   50
                                               In May 2006 the President of Burundi announced that
                                               maternity services would be provided free of charge
                                   40
                                               and since then additional public financing has been
                                               allocated to meet the rising demand for services
                                   30


                                   20


                                   10


                                    0
                                                                                                                           20
                                        2000      2001      2002       2003      2004      2005      2006       2007      2008
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/


                                                                            21
                              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



                                                                                  22
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
                                           23
   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
                                                                     24
Thank you!   25

								
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