1. The lack of free access to health services and the impact on implementation: the user fees and their impact

2. 2 Why were user fees introduced? Argument 1: user fees improve efficiency Reduce unnecessary demand Reduce inappropriate use of referrals Encourage people to take better care of themselves Increases ownership of health services In practice… Patients are not doctors Free care at the point of delivery does not mean that to seek care is free User fees will not reduce the demand of the richest patients In most places, users are not empowered “customers”.

3. 3 Why were user fees introduced? Argument 2. user fees raise financial resources shifts part of the costs to the patient and frees public funds user charges will raise additional revenues brought new funding for health facility level In practice… The revenue raising potential of user fees has been very low, about 5% of healthcare expenditure assumption that utilization by patients will not fall

4. 4 Why were user fees introduced? Argument 3: A cost recovery system improves the equity of the health system User fees could eliminate inequity by raising revenue to improve quality and coverage for the poor Frees government resources to be allocated towards the poorest Exemption systems In practice… Exemption systems do not work Excludes the poor from healthcare Revenue rarely kept at local level

5. 5 Elimination of user fees could prevent approximately 233,000 (estimate range 153,000-305,000) deaths annually in children aged under 5 in 20 African countries.(BMJ 2005)Elimination of user fees could prevent approximately 233,000 (estimate range 153,000-305,000) deaths annually in children aged under 5 in 20 African countries.(BMJ 2005) Immediate and increased utilisation rate for maternal and child health servicesImmediate and increased utilisation rate for maternal and child health services Ends the situation that user fees are not a source of income, they are a form of rationing, based on wealthEnds the situation that user fees are not a source of income, they are a form of rationing, based on wealth People should pay for healthcare according to their ability, but receive health care according to need.People should pay for healthcare according to their ability, but receive health care according to need. Benefits

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10. 10 Emerging Consensus UK Government led the Taskforce on Innovative Financing and 23 September 2009 eventUK Government led the Taskforce on Innovative Financing and 23 September 2009 event Global Consensus on MNCH supports removal of fees “where countries choose”Global Consensus on MNCH supports removal of fees “where countries choose” Consensus warmly welcomed by the G8 2009 L’Aquila including removal of fees “where countries choose”Consensus warmly welcomed by the G8 2009 L’Aquila including removal of fees “where countries choose” World Bank HNP Strategy 2007: “Upon client-country demand, the Bank stands ready to support countries that want to remove user fees from public facilities if……..” with multiple reservationsWorld Bank HNP Strategy 2007: “Upon client-country demand, the Bank stands ready to support countries that want to remove user fees from public facilities if……..” with multiple reservations Margaret Chan: “please let’s work together to support countries to implement ways to get rid of all these barriers and most important of all user fees.”Margaret Chan: “please let’s work together to support countries to implement ways to get rid of all these barriers and most important of all user fees.” EC Council Conclusions 2010EC Council Conclusions 2010

11. 11 Senegal free deliveries 2006 Liberia all services free Feb 2007 Niger free for <5s and deliveries 2006 Kenya free deliveries Oct 07 Sudan free services for <5s and c-sections Feb 2008 Uganda all services free Mar 01 Burundi free for <5s and deliveries Aug 06 Zambia free services in rural districts Apr 06 The Rapid Removal of Health User Fees in Africa since 2000 Lesotho free services at primary level Jan 08 Countries introducing free services since 2000 Countries with free services pre 2000 Ghana free services for children and pregnant women May 08

12. 12 Arguments made in Sierra Leone Focus on MDGs 4 and 5Focus on MDGs 4 and 5 A proven quick-win in terms of improving accessA proven quick-win in terms of improving access Strong efficiency and equity argumentsStrong efficiency and equity arguments Allows space for other public and private mechanismsAllows space for other public and private mechanisms Can be achieved only for under 5s and pregnant and lactating womenCan be achieved only for under 5s and pregnant and lactating women Countries can define their own package of servicesCountries can define their own package of services Consistent with universal coverage and rightsConsistent with universal coverage and rights Many LICs are doing this anyway – not donor- ledMany LICs are doing this anyway – not donor- led

13. 13 Preparation for 27 April 2010 analyze country situationanalyze country situation set up of steering group and 6 sub committees in areas of HR, Logistics & drugs, communications, M&E, finance & governance and infrastructureset up of steering group and 6 sub committees in areas of HR, Logistics & drugs, communications, M&E, finance & governance and infrastructure weekly sub-committee update on progressweekly sub-committee update on progress Save the children co-chaired the communications sub committeeSave the children co-chaired the communications sub committee launch on independence day (April 27)launch on independence day (April 27)

14. 14 Success: Crowd waiting at the PCM Hospital

15. 15 Success; beneficiaries waiting for services at Goderich community health centre

16. Thank you for listening Amie Lompri Koroma Health Programme Officer Save the Children, Sierra Leone