Removing financial barriers to access reproductive, maternal and newborn health services: the challenges and policy implications for Human Resources for Health (HRH) Barbara McPake, Sophie Witter, Tim Ensor, Suzanne Fustukian, David Newlands, Tim Martineau

Growing consensus that user fees are regressive; undermine equitable access to health services; constrain improved health for pregnant women and children under five Many low and middle income countries reconsidering levying user charges: reinforcing exemption mechanisms, significant reduction in fee levels or abolition altogether Consequences for the health system: search for replacement revenue; response to changes in utilization Specific concerns for human resources for health Demand side support requires balance with supply side support

The objective of this research was: To explore the associations and interrelationships between workforce characteristics (stock, distribution, competencies and motivational state) and equitable access to Reproductive Maternal and Newborn Health (RMNH) services resulting from the removal of, or exemption from user fees.

Research questions In priority countries, what is the evidence on the impact of – fees, exemptions and fee removal on HRH; – and of HRH characteristics on the impact of fees, exemptions and fee removal?

In each of Sierra Leone, Zimbabwe, Zambia, Nepal and Ghana and where possible, before and after a change in user fee policy: What is the distribution and skill mix of the RMNH workforce? What is the workload managed by the RMNH workforce What data are available about the remuneration and terms and conditions (including deployment procedures)

What are the projected needs for RMNH workforce given standard estimates of capacity per FTE by cadre? What plans are in place to improve RMNH workforce capacity both quantitatively, qualitatively and with respect to geographical distribution? What formal fees exist for RMNH services? Where are revenues from formal fees retained and how are they used?

What exemption policies exist and how are they applied? What evidence is available of the demand suppression effect of formal fees? What are the policy implications of the evidence from questions (i) to (viii)?

Methods Literature review (not included in presentation) Desk based data analysis and document review Field studies in Sierra Leone and Zimbabwe

Policy context: Ghana Exemptions introduced for delivery care 2004 first in 5 regions, then across country Policy later superseded in 2008 by free coverage of all pregnant women within National Health Insurance Scheme (NHIS) Both policies undermined by poor availability of funds Government HRH policy focused on task shifting and improving distribution including deprived area incentives scheme Large pay increases : significant expansion of training schools

Policy context: Nepal In principle, all citizens have free access to primary care Targeted groups also protected from secondary care costs Policies undermined by shortfalls in funding 2008 Aama policy: free institutional deliveries in all public and some private facilities 2005: financial incentives for women to delivery in a facility Target of 71% increase in public sector workforce by 2017 – emphasis on SBA competent health providers

Policy context: Sierra Leone Free Health Care Policy – free public care for pregnant and lactating women and children under 5, April 2010 Substantial salary increases, 2011 Performance based financing system being introduced 2011 HRH policy plans incentives for hard-to-reach areas and reformed career paths and recruitment processes

Policy context: Zambia User fees abolished for rural primary care in 2006, peri-urban areas 2007; government and mission facilities Compensation for loss of revenue through DFID grant HRH policies – training and recruitment of graduates; developing HR information systems, scaling up of Zambia Health Workers Retention Scheme offering salary top-ups in remote areas

Policy context: Zimbabwe Policy of free care but inconsistently applied Perception that charging can be locally determined Dollarization of economy may have increased real value of fees HRH expenditure collapsed to 0.3% of public health budget in 2008 Emergency Retention Scheme introduced, but to be phased out by 2013 HRH strategic plan: retention of staff key priority

Effects of user fee policy change on utilisation Ghana: delivery exemption modest gains in utilisation and equity; increased in use of formal care for members of NHIS but not maternal care; increased use of OPD in population since NHIS introduction Nepal: utilisation rates of disadvantaged groups improving and substantial increase in facility births since Aama

Sierra Leone: impact of FHCP mixed; immediate increase in OPD use but decline since; falling immunisation rates; increases in maternal health service use Zambia: increased OPD utilisation for adults but not consistent across districts and some evidence of crowding out of under 5s who previously received free care. Zimbabwe: no discrete financing policy change

Distribution of health workforce by cadre

Distribution of health workforce by sector

Delivery workload for skilled birth attendants and doctors: actual rate of facility based deliveries and full coverage (all births) Births per SBA Births per doctor Deliveries per SBA Deliveries per doctor Ghana 2010/ Nepal Sierra Leone Zambia Narrow Zambia Broad13352 Zimbabwe

Public sector remuneration (salary midpoints incorporating allowances) in international dollars and as a ratio to GNI per capita (all current: December 2011) Value of salary and allowances in Int$ Salary expressed as ratio to p.c. GNI Doctor ∆ NurseMidwifeDoctorNurseMidwife Ghana Nepal Sierra Leone ® 578° ® 8.4° Zambia Zimbabw e*

Assumptions and results for staff requirements for scaling up skilled birth attendance in Nepal, Sierra Leone and Zambia Doctors Skilled birth attendants Common assumptions Deliveries/year Salary growth3% Nepal Attrition5% Baseline salary (current US$) Scale-up needed43-95% Additional staff needed (109% increase) Annual cost in 2015(current US$) 6,003,62117,661,052

Sierra Leone Attrition5% Baseline salary (current US$) 1, Additional staff needed 21 (9% increase)1212 (515% increase) Scale-up needed44-95% Annual cost (current US$) 374,352896,024 Zambia Attrition5%10% Baseline salary (current US$) 18,2468,581 Scale-up needed47%-95% Additional staff needed 382 (29% increase)2464 (47% increase) Annual cost (current US$) 12,693,52435,527,457

Conclusions Is there an HRH crisis? – Situations quite varied – Shortages mainly driven by poor internal distribution Health workers are relatively well paid with some exceptions Shortages of SBA staff matched by questions about the competence of those counted Utilisation impacts of user fee removal variable – case studies confirm importance of supporting supply side Some effort to co-ordinate HRH and financing polices with mixed success Data gaps huge