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. 22 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 covered costs)

3. 33 The three dimensions of universal coverage: Couverture de la politique dexemption Exemption policy coverage

4. 44 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 -…

5. 55 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

6. Result of part 1

7. 77 Chronology of the policies introduction Burkina Faso C-section Burkina Faso C-section Niger Morocco Benin Mali Sierra Leone Ghana Phase 1 Ghana Phase 1 Senegal Phase 1 Senegal Phase 1 Ghana Phase 2 Ghana Phase 2 Burundi Child under 5, Delivery, C-.Section Burundi Child under 5, Delivery, C-.Section Senegal Phase 2 Senegal Phase 2 Ghana Phase 3 Ghana Phase 3 2005200620072008200920102004 Kenya Phase 1 Kenya Phase 1 Kenya Phase 2 Kenya Phase 2 Kenya Phase 3 Kenya Phase 3 2011 Nigeria Phase 1 Nigeria Phase 1 Nigeria Phase 2 Nigeria Phase 2 Burkina Faso Delivery Burkina Faso Delivery Burundi Pregnancy- related diseases Burundi Pregnancy- related diseases

8. 88 Who is covered? Benin Mali Senegal Burkina Faso Burundi Ghana Kenya (according to income) Morocco Niger Nigeria Sierra Leone (+ breastfeeding women)

9. 99 In what area of the country? Kenya: some regions only Nigeria: some regions only Senegal: Dakar not covered Benin Burkina Faso Burundi Ghana Morocco Mali Niger Sierra Leone Everywhere Targeted regions

10. 10 In which hospitals? Benin Burkina Faso Burundi Kenya Ghana Nigeria* * except at tertiary level hospitals

11. 11 Which services are covered? ++++++ DC = Directs obstetric Complications Hyster = hysterectomy Ect.P = Ectopic Pregnancy Morocco Burundi Ghana Burkina-Faso Kenya Nigeria Sierra Leone Senegal Mali Niger Benin Antenatal care Delivery Episiotomy Complication during pregnancy DC Complication during labour Caesarean section Other surgeries Hyster. Hyst+Ect.P Postnatal care Postnatal complication Postnatal family plnning Simple post-abortion care Complicated post-abortion care Newborn care Covered by another exemption or subsidy policy

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

13. 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 $)

14. 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

15. 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. * Ghana has exemption for Children under 18 enrolling onto the NHIS.

16. 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).

17. 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 ?

18. 18 Targeted exemption policies : can we do better? Pregnant women Under five Elderly … Health centre Hospitals, 1 st, 2nd, 3rd level? C-section & Deliveries TB, Malaria, HIV Family Planning