1. Abt Associates Inc. In collaboration with: I Aga Khan Foundation I BearingPoint I Bitrán y Asociados I BRAC University I Broad Branch Associates I Forum One Communications I RTI International I Training Resources Group I Tulane Universitys School of Public Health October 26, 2009 USAID/Washington Revitalizing Community-Based Health Financing in Africa Cheikh Mbengue

2. Outline for presentation Why CBHF? Trends in CBHF and USAID technical approach in Africa Lessons and opportunities New CBHF strategy for Africa Application in Niger and Mali Expected outcomes

3. Out-of-pocket expenditures dominate health financing in Africa and Asia

4. Why should USAID support CBHF in Africa? 44% of total health expenditures in Africa come directly from households out-of-pocket (OOP) OOP: impoverishing, inefficient, limit access to care Traditional health insurance is hard to establish where: Economy is dominated by informal sector Majority of population is rural poor Influx of external health funding has been stymied by limited absorptive capacity

5. CBHF formed the basis for scaling up to national insurance coverage in both Ghana and Rwanda CBHF can effectively reach informal sector and vulnerable populations Other international donors (World Bank, ILO, GTZ) are becoming more open to mixed models for insuring populations Why should USAID support CBHF in Africa?

6. CBHF trends in Africa CBHF movement is active in West and East Africa Spectrum of CBHF scale-up as of 2009: Moving towards universal coverage/integration into national health insurance schemes: Ghana, Rwanda Growing population coverage: Senegal, Benin, Mali Incipient efforts: Burkina, Cameroon, Cape Verde, Ethiopia, Guinea, Mauritania, Niger, Togo

7. USAID has used a variety of approaches to support CBHF Centrally-funded project support (PHR, PHR plus, PRIME 2) Individual grassroots TA to MHOs; development of toolkits ; research to evaluate effectiveness, and support to regional network La Concertation Regional project support – AWARE-RH Mixture of TA to MHO support organizations, national policy development, and support to regional network La Concertation Bilateral project support, e.g. Senegal, Rwanda, Benin Rwanda: TA to MHOs through district-level networks of MHOs and local governments Senegal: TA to MHOs through NGOs and subnational networks of MHOs Benin: TA to MHOs through support to district-level networks of MHOs and partnerships with local governments

8. USAID has used a variety of approaches to support CBHF

9. What are some lessons learned? Supportive policy environment and institutional arrangements are essential to facilitate rapid scale-up Government involvement and ownership is essential Different donors, organizations, and project mechanisms can effectively provide complementary inputs Constant need for program promotion when insurance membership is voluntary Capacity to implement CBHF is limited at all levels TA to individual schemes (especially by external consultants) is very labor intensive, expensive, and not locally sustainable Need for monitoring to manage risk, quality, and sustainability Need for evaluation to measure impact

10. What are the gaps / opportunities? Lack of local capacity to implement national CBHF strategies National networks that advocate for the implementation of the strategies are weak Existing MHOs are not receiving the systematic support they need to become sustainable, expand coverage, or create networks with other MHOs Piecemeal health financing reforms Abolition of user fees – can increase access but may diminish consumer interest in insurance, hurt service quality at the facility level, and lead to informal fees Incipient national health insurance – how to integrate existing CBHF schemes?

11. Technical tools to support the development of integrated health insurance models, including MHOs (e.g. training manuals, guidelines) Trained international and local personnel with grassroots- and national-level experience National strategies as models for the way forward (Benin, Senegal, Rwanda, Ghana) Explosive interest in health insurance and growing consensus that CBHF can be part of the health insurance scale-up Other key donors such as ILO, GTZ, French Cooperation, Belgian Cooperation, and European NGOs are active and engaged ---- what is the way forward for USAID? What strengths do we have to build on?

12. The way forward – CBHF strategy for Africa Strengthen institutional capacity at the national and intermediate levels to advocate for and drive implementation of national strategies Local government agencies – e.g. municipal and district authorities in Rwanda Local/sub-national networks of MHOs – e.g. MHO networks in Benin National network – e.g. CNC in Niger Develop national strategic plans where they do not yet exist (e.g. Mali) Replace user fees with premium payments to CBHF schemes to promote membership and sustain financing for service providers Find out what works – Assess the relative effectiveness of supporting MHO development through national networks, national NGOs, and local MHO networks

13. Strategy: Provide support at the national and intermediate levels for CBHF scale-up in selected countries Regional and national policy development Expensive external TA to individual MHOs Local NGO and government capacity to implement national strategies and provide sustainable technical support to grassroots MHOs Health Systems 20/20

14. 10 patients pay $10 each MOH allocates $100 Provider $200 User fees w/o CBHF Strategy: Integrate user fee policies with CBHF to promote membership, sustain financing for service providers

15. 10 patients pay $10 each MOH allocates $100 100 patients pay nothing MOH allocates $100 Provider $200 User fees w/o CBHF Free care w/o CBHF Provider $100 Strategy: Integrate user fee policies with CBHF to promote membership, sustain financing for service providers

16. 10 patients pay $10 each MOH allocates $100 100 patients pay nothing MOH allocates $100 Provider $200 User fees w/o CBHF Free care w/o CBHF 100 patients pay $1 premium CBHF pools & purchases Provider $200 Link user fees w/ CBHF MOH allocates $100 Provider $100 Strategy: Integrate user fee policies with CBHF to promote membership, sustain financing for service providers

17. CBHF Strategy for Africa: Applications in Niger and Mali

18. Niger s national CBHF strategy not implemented Rapid assessment of current status of CBHF National CBHF strategy in place since March 2008 Not implemented due in large measure to lack of implementation capacity and resources Health Systems 20/20 s approach: Foster partnership between Gov t of Niger and CNC (national network of organizations that support MHOs) Strengthen CNC s capacity to implement national strategy

19. Niger strategy in action Conducted a national-level workshop to develop the advocacy skills of CNC members Working with the Government of Niger and CNC to develop an operational plan to implement the national strategy Planning a workshop to strengthen the capacity of CNC and NGOs staff to create and support MHOs

20. Expanding CBHF in Mali No prior national strategy for CBHF Piecemeal reduction of user fees Ministries of Social Welfare (MSW) and Health (MOH) have overlapping interests Government wants to expand CBHF and subsidize premiums for the poor Health Systems 20/20 s strategy Partner with MOH, MSW, and international donors to develop and implement a national strategic plan for CBHF scale-up

21. Mali strategy in action Results to date: Health Systems 20/20 partnering with Gates-funded Ministerial Leadership Initiative and World Bank Working closely with MOH and MSW to develop strategic planning process Conducted first of two national-level consultations to develop the plan Subcontracted with UTM, a key national NGO created by Malian MHOs, to strengthen three MHOs in Sikasso Next steps: Second national consultation on Mali s national CBHF strategy Develop a plan to operationalize the strategy Continue strengthening of MHOs in Sikasso through UTM Through UTM (and in partnership with the regional office of the MSW and NGOs) develop an MHO network in Segou Region for existing MHOs

22. Expected regional and country outcomes Concrete on-the-ground impact in Mali and Niger More and stronger CBHF schemes, more people covered, local capacity strengthened to implement CBHF Lessons learned about how to strengthen local implementation capacity to expand and sustain CBHF coverage New tools for local organizations Assessment framework for CBHF scale-up Assessment of existing MHO performance Roadmap to establish a sub-national network of MHOs Sample operational plans for national CBHF strategies

23. Abt Associates Inc. In collaboration with: I Aga Khan Foundation I BearingPoint I Bitrán y Asociados I BRAC University I Broad Branch Associates I Forum One Communications I RTI International I Training Resources Group I Tulane Universitys School of Public Health Thank you. For more information visit www.healthsystems2020.org