Presentation on theme: "HOW TO IMPROVE ACCESS TO REHABILITATION SERVICES FOR POOR PERSONS IN AFRICA? EVALUATION OF THREE REHABILITATION EQUITY FUNDS SET UP IN MALI, RWANDA AND."— Presentation transcript:
HOW TO IMPROVE ACCESS TO REHABILITATION SERVICES FOR POOR PERSONS IN AFRICA? EVALUATION OF THREE REHABILITATION EQUITY FUNDS SET UP IN MALI, RWANDA AND TOGO. Rozenn Botokro – West Africa Rehabilitation Advisor – Amman - Jordania - December 2009
Context and actors analysis Mali 173/177 ; Rwanda 161/177 ; Togo 152 Persons with disabilities are Among the poorest of the Poor (Elwan) 15 to 20 per cent of the poor in developing countries (Helander) no incomes and no insurance less opportunities of support
Context and actors analysis Low attendance of the rehabilitation centres Capacity of the centres to take on more activity No free care, no individual cash transfers by the States Very low willingness and capacity (Mali, Togo), some willingness and low capacity (Rwanda) of the State
Handicap International is working in Mali, Rwanda and Togo for years in the field of rehabilitation These 3 Rehab Equity Funds (or HEF) are little parts within three different rehabilitation projects designed by different people at different times, with different funding sources = no interaction between them.
Equity funds One goal : Paying the provider on the poorests behalf Two principles (Noirhomme & al.): - specific fund allocated to pay selected services to deliver quality care at given rate - Management of the fund entrusted to an independant « purchasing body » or to another institution to which the third-party payer delegates this role
TIERS-PAYANT INDEPENDANT PURCHASING BODY PRESTATAIRES (PROVIDERS) USAGERS DES SERVICES (USERS) To identify users, to assess poverty, to monitor beneficiaries to monitor the quality and cost of the care provided To make all necessary refund Management
Beneficiaries Over 3 years, the Rwanda HEF has helped provide rehabilitation care to 819 people, against 591 for Mali and 308 for Togo. Women represent the majority of beneficiaries in Rwanda (54%) and Mali (60%). However, they account for only 45% of beneficiaries in Togo. The average age of beneficiaries is 25 years in Rwanda, 31 years in Mali and 30 years in Togo.
Functioning RwandaMaliTogo Financing of the Rehabilitation project EU (66%), HI France (34%)EU, Luxemburg, RRA* HI Lux and HI France EU (75%), HI France (25%) Project duration2006 – 2008 (3 years) Presence in the project of a person dedicated to HEFs NoYes Scope of HEFsNational (All 5 regions)Regional ( 5 of 9 regions)Regional (1 of 6 regions) Number of service providers producing orthopaedic devices 542 Number of other service providers 003 physiotherapy departments and 2 ironworks Rates paid by the HEF to the centres National rates Rates determined by the centres Mandatory contributionNoYes
Responsibilities RwandaMaliTogo Identification of applicantsNo identificationPublic social services, HI workers, and DPOs Disabled Peoples Organizations (facilitators) Selection of beneficiariesSocial services of the hospitalsHI workers, head of the HEF (HI staff) SYSTER committee Refund of the HEFOfficially, FENAPH. De facto, HI HISYSTER committee, with HI support Physiotherapy carePublic hospitalsAutonomous public rehabilitation centres Autonomous rehabilitation centres, district hospitals, and autonomous physiotherapy centres Production of orthopaedic devices Public hospitalsAutonomous public rehabilitation centres Autonomous rehabilitation centres (1 private and 1 public centres) Production of tricyclesNo tricyclesAutonomous rehabilitation centres and private workshops Monitoring of beneficiariesDisabled Peoples OrganizationGovernment social services, HI workers Disabled Peoples Organization and SYSTER committee
Cost calculation only costs covered by HI to answer the following question: how much does it costs the facilitating organization to launch and implement an HEF? Expenses required for the setting up and/or operation of the fund have been taken into account.
overall cost varies greatly : 229,000 euros for Mali, 186,000 euros for Rwanda and 120,000 euros for Togo. average rehabilitation cost per beneficiary is similar from one country to another: 140 euros for Rwanda, 175 euros for Mali, and 193 for Togo more differences in the average overall cost per beneficiary (which includes the costs of rehabilitation as well as the operating costs). Cost calculation
Average rehabilitation cost and average total cost for 3 years, per beneficiary (in euro)
Effects on the beneficiaries HEFs have undoubtedly allowed very poor people with disabilities to have access to rehabilitation services which were previously inaccessible to them, thus enhancing their autonomy.
Structural effects HEFs enable rehabilitation services to develop their activity HEFs could create jobs in health facilities, but also in private workshops where crutches and tricycles are produced. - HEFs strengthen the credibility of DPOs vis-à-vis the State and the community
HEFs prove to the State the importance of a strong response to the needs of the poorest Persons with Disabilities, and show that it is quite possible to improve their social inclusion. and encourage the State to create rehabilitation services and train professionals. Structural effects
more generally effects HEFs make the different rehabilitation stakeholders collaborate more (Rehab services, hospitals, social services, DPOs, ministries...) HEFs popularize rehabilitation services among in communities.
HEFs educate everyone on the right to rehabilitation. HEFs could create jobs in health facilities, but also in private workshops where crutches and tricycles are produced. more generally effects
The advantages of HEFs over other methods of financing FR care In countries which have opted for a cost recovery policy : three options: mutual insurance companies (public or private), HEFs, or exemption Exemption Full exemption requires strong political will and funds exemption would be in strong contradiction with the principle of cost recovery.
mutual insurance system It seems completely impracticable for rehab needs : the sums required are higher than for basic care, whereas Persons with Disabilities are poorer than average, the needs of these people are ineluctable. However, no physically disabled person is exempt from rehabilitation expenses (particularly as physical therapy can take a long time, and devices have to be maintained and renewed regularly).
Sustainability, the main challenge State : funded by the government through taxes, or by public national insurance companies which accept to devote a portion of the subscriptions of their members to the HEF, which would however be in violation of their sustainability principle. Another option : "basket-funds" credited by different institutions. two constraints: -To regularly look for new contributors to counter the possible withdrawal of those already involved. -It requires that the contributors agree on who will be responsible for managing the HEF.
Recommendations What not to do in order to make an HEF successful: Entrust the management to a service provider Use selection procedures that are too complicated Fund micro credits or IGAs using an HEF Determine contributions on the basis of the total cost of the care Not apply the same rules to all
What to do to contribute to the success of an HEF Entrust the management to national institutions established locally right from the beginning Target beneficiaries through an effective identification system Conduct rigorous surveys with beneficiaries Systematize the payment of a contribution
Better take into account the specific case of growing children Better take into account patients who need physical therapy only Reduce the time between patient identification and device delivery Continue to support FR services as regards the biggest expenses What to do to contribute to the success of an HEF
Key points : The existence of donor funding The presence of a driving agent Clear separation of roles Appropriate identification techniques Holistic consideration of barriers to utilization of services