Is Free Care Truly Free and Equitable? The Case of Liberia CHALLENGES & LESSONS LEARNED S. Tornorlah Varpilah Tesfaye Dereje Chris Atim

Major Health Indicators IndicationValueYearReference Population3,476, National Census Infant Mortality Rate712007LDHS Under Five Mortality LDHS Child Mortality412007LDHS Life Expectancy Human Dev. Rep. (UNDP) Total Fertility Rate LDHS Maternal Mortality Rate LDHS Immunization Coverage (Full)51%2007/08NHA Total Health ExpenditureUS 100,517, Country Situation Rep. (MOHSW) GOL health Expenditure as % of total government expenditure 7.73%2007/08NHA

Major Causes of Morbidity

Basic Package of Health Services –Maternal and Newborn health –Child Health –Adolescent, Sexual and Reproductive Health –Disease prevention, control and management –Essential Emergency Treatment Liberia’s Free Health Care Policy 4

No User fee Policy Mandate “In light of crushing levels of poverty, the ministry has decided to suspend user fees at the primary health care level” “Suspension will remain in place until the socio-economic situation improves and financial management systems perform” National Health Policy (P. 14) “In accordance with MOHSW policy, user fees for services included in the Basic Package will be suspended at all public facilities” National Health Plan (P. 6) 5

Total Health Spending ~ $105 Million (~$29 per capita) Source: MOHSW, National Health Account 2007/08 6 Health Financing Landscape Households 35% Government 15% Donors 47% Other Private 3% Private Providers 53% Black Baggers/ shops 19% Government Facilities 15% Pharmacies 9% Traditional Healers 4%

Burden of HH Health Spending Share of Health Spending out of total Household Spending –Overall: 3.3% –For Households that reported out of pocket spending: 9% (catastrophic by the 5% rule of thumb) The burden worsens for the lower income households Share of Household Spending on Health (Among HHs that Reported OOP) Wang, 2009: Using 2008Community Survey data 7 Rural Urban

Who’s Utilizing Government Health Services? Cumulative Share of Households Cumulative Share of Public Health Service Utilization Cumulative Share of Households Cumulative Share of Public Health Service Utilization Government Health Service Utilization by Expenditure Deciles 8 Source: Ashagari & Wang, Benefit Incidence Analysis 2010

Distribution of Public Subsidies Generally, pro-rich distribution of Public subsidies (CI =0.203) slightly pro-poor at the clinic level; but Pro-rich when it comes to hospitals and health centers 9 Source: Ashagari & Wang, Benefit Incidence Analysis 2010

Shortage of Pharmaceuticals Ensuring drug availability is still challenging for both –drugs flowing through National Drug Service and –vertical programs An average 50% of Health Facilities face drug stock-outs at a particular point –Proportion of facilities with no stock-outs varied from virtually none to nearly 70%, ending the year around 50%. (Assessment of 103 facilities in 7 counties revealed (in 2010) From households perspective: –Two-thirds complained about difficulties in accessing drugs (Community Survey for Health Seeking Behaviour) Concerns about leakage of drugs at facility level. 10 MOHSW/OPM, Health Financing Situational Analysis, 2011

Poor Physical Access Average distance from Communities to Health Facilities by Counties Average distances to the nearest facility in most counties well beyond the effective 5 K.M. radius (one hour) established by the BPHS Source: MOHSW, Country Situational Analysis Report (Draft),

Unequal Distribution of Health Facilities Number of Clinics and Size of Catchment Population (2010) Basing Liberia’s BPHS Standard: 40% cater to population below threshold 10% are over- catering Source: MOHSW, Country Situational Analysis Report (Draft),

Poor Clinical Quality Source: Quality Assurance Baseline Assessment Report (RBHS) Nov

Shortage of trained clinical health workers Weak supply chain management system Inadequate health facilities Weak M&E system Lack of standardized budgeting mechanism Weak regulatory system for workers Challenges/ Imbalance

Progress on Production Targets

Lessons Learnt (1) Know the cost implications –Actuarial calculation taking into account anticipated utilization increases Institute effective targeting mechanisms Explore room to increase/ reallocate resources to the identified priority area 16

Lessons Learnt (2) –Strengthen supply chain management system –Strengthen regulatory system –Strengthening Results Based Financing –Improve budgeting mechanisms to link resources required to health outcomes 17

Lessons Learnt (3) Establish an effective monitoring and evaluation system Strengthen aid coordination mechanism Increase the number and quality of health workers 18

Conclusion Free Care (user fee removal) is not the final answer If unaccompanied by additional reform measures to tackle expected supply side constraints (esp. given it generates demand that require catering) it: –Over-stretches the resources available at the public facilities with an impact on level and quality of services provided –Forcing the population to seek alternative care which tend to be either more expensive (private providers) or ineffective/dangerous (black baggers). 19