1. Fee exemption policies for maternal health care: some issues from the field of health economics Technical workshop on the benefits package for fee exemption policies for maternal health services – Bamako 17-19 November 2011 Bruno Meessen & Matthieu Antony

2. Objectives Free care has several merits, but it also has a cost. Identify some key issues relating to health economics and provide food for thought on fee exemption policies.

3. 33 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

4. How to allocate resources?

5. The determinants of budgetary weight of exemption policies The targeted population and fertility rate as a crucial factor The range of services included in the policy The costs covered by the policy Exemption policy coverage

6. Different criteria, different winnings Criteria: support by citizens (benefits, justice) Criteria: protection against catastrophic expense Key question: which is the optimal cube in terms of winnings for populations (possibly with different weights), givens limited resources, systemic issues and dynamics? Criteria: cost-effectiveness Exemption policy coverage

7. Year 2010 MoroccoGhanaBurundiBurkina-FasoKenyaNigeriaSierra LeoneSenegalMaliNigerBenin Amount allocated to maternal health care funding (in PPP$) --10 410 789----- 6 657 455 (2009) 4 847 560 (2009) 8 689 281 Amount allocated to maternal health care and newborn funding (in PPP$) 62 876 604--14 410 7898 897 766------ Amount allocated to maternal health care and children under 5 years funding (in PPP$) --27 355 978-- 59 471 658 (nov 2008- june 2010) 11 673 382-- 17 223 343 (2009) - Antenatal care Delivery Episiotomy Complication during pregnancy DC Complication during labour Caesarean section Other surgeries Hyster. Hyst+Ect.P Postnatal care Postnatal Complications Postnatal family planning Simple post-abortion care Complicated post-abortion care Newborn care DC = Directs obstetric Complications Hyster = hysterectomy Ect.P = Ectopic Pregnancy Covered by another exemption or subsidy policy

8. Example : estimation of unit cost of C-Section

9. Available fiscal space, political commitment

10. Sources : authors' calculation

11. Resource mobilization State budget only – Benin – Burkina Faso – Ghana – Morocco – Nigeria – Senegal State budget and Foreign aid – Burundi – Kenya – Niger – Sierra Leone

12. Share of foreign aid in the exemption policy funding

13. Features of foreign aid The aid is mainly but not only monetary… – Niger : aid is monetary and non-monetary (drugs, contraceptives, transport in the case of referrals) Multiplicity of donors – Sierra Leone : DfiD, World Bank, AfDB, UNFPA Donor commitment? – Burundi and Kenya: funding commitment from donors until 2014 – Niger and Sierra Leone : Donor commitment does not specify duration – Burkina Faso : no commitment => Sustainability of policy funding an issue?

14. Forecast versus actual disbursements in 2010 * Maternal health care only

15. How to compensate providers for delivering free services? The incentives issue

16. The issue User fees are a mechanism for rationing scarce government resources (and development partners) but are also part of a set of incentives for providers By removing it, (1) set up another system of incentives; (2) exposure to another form of rationing (stock-outs, burn-out…)

17. Incentives / Effects For users: – Access – Distortion that may shift demand (i.e. Benin). For providers: – Effort in terms of quantity of services produced – Effort in terms of quality of services provided to users – Effort in terms of the management of resources within health facilities or the health system – Effort in terms of reporting For donors: – Effort in terms of resource mobilization – Effort in terms of disbursement

18. Funding arrangements Impact on drugs supply: « push » or « pull »? Parallel system?

19. Different approaches to fixed fee Unique fixed fee regardless of level of care (Benin, Mali, Morocco, Nigeria). Fixed fee depending on level of care (Niger, Ghana*). * In Ghana's case this depends on the ownership of the facility as well as the level. Kenya : fixed fee depends on ownership of health facility (public, faith-based / NGO, private for profit). Burundi : one fixed fee but «equity bonus system». Burkina Faso : reimbursement of health facilities based on the actual cost of care. Key question: Does the fixed fee cover marginal cost? Does it take into account staff motivation? What effects, distortions?

20. Performance-Based Financing: interesting option? Combination between selective free and Performance-Based Financing (Burundi). Principles: – A purchasing agency offsets each patient accepted according to a standard fee that builds in an amount for staff incentive. – Compensation can be a criteria in terms of quality of care. – Facility has enough autonomy to decide on the use of resources (i.e. Burkina Faso). – A verification agency checks the physical reality of the benefits reported. Difficulty: assessing the quality of maternal health care (Caesarean section)

21. Frequency of reimbursements/prepayments Mali (reimbursements) Nigeria Are there any delays in the reimbursement of health facilities that threaten their financial health (debt accumulation)?

22. Conclusion Free care through fee exemptions has a significant cost to governments. Crucial issue! We are looking for the optimal system. It is important to explain the decision criteria. Some options raise questions. There is no single funding strategy for exemption policies. Dont neglect the accompanying measures and the key role of incentives => Importance of formulation phase (design!) and implementation. Need for a good information system to correct the adverse effects.