1. A. Letourmy, CERMES- CNRS, Antwerp, 18 December 2003 The access of poor people to health services in French speaking Africa Alain Letourmy (CERMES-CNRS) Antwerp, 18 December 2003

2. A. Letourmy, CERMES- CNRS, Antwerp, 18 December 2003 Plan of the presentation 1- Health policies concerning poor people in West Africa 2- How to give poor people access to health services when they are sick ? 3- How to give poor people access to health insurance ?

3. A. Letourmy, CERMES- CNRS, Antwerp, 18 December 2003 1-1Health policies and consequences for poor people Two constraining elements with regard to the access of poor people to health services : cost recovery and reforms establishing the financial autonomy of health care facilities The Bamako Initiative : an improvement or a supplementary barrier for poor people ? Financial autonomy : payment of users and cost control as more important issues for health care facilities, especially for hospitals Consequence : illusion of social prices (eg real user cost of a caesarian delivery in Burkina)

4. A. Letourmy, CERMES- CNRS, Antwerp, 18 December 2003 1-2 Special policies towards poor people Free access (re)established for certain categories of users : in case of specific diseases (AIDS, TB, etc.), for pregnant women, for infants, for poor people The obligation of care in case of emergency, even if people cannot pay The specific procedures concerning poor people : –certificates of indigence –ear-marked budgets allocated to health care facilities

5. A. Letourmy, CERMES- CNRS, Antwerp, 18 December 2003 1-3 The effectiveness of special policies The global result is a financial burden for health care facilities What effectiveness for poor people ? False indigents Commitment without payment for the institutions delivering certificates The new behaviour of health care facilities when they receive ear-marked budgets : moral hazard (RCI)

6. A. Letourmy, CERMES- CNRS, Antwerp, 18 December 2003 2-1 Some experiments and projects to give poor people access to health services Two kinds of solutions : general ones and local ones Local ones : “Caisses de solidarité” (Solidarity funds) and Selingue experimentation (Local Medical Assistance Fund) General ones : National Medical Assistance Fund (Mali)

7. A. Letourmy, CERMES- CNRS, Antwerp, 18 December 2003 2-2 Local solutions : Solidarity Funds (Caisses de solidarité) in Mali) Goal : a better organisation of referrals in case of dystocy ie access to the adequate level Cost sharing between upper level (district), primary care unit (ASACO) and user Results : improvements in terms of maternal mortality Dissemination and project of implementing mutual societies in order to share the risk Question : exclusion of very poor people ?

8. A. Letourmy, CERMES- CNRS, Antwerp, 18 December 2003 2-3 Local solutions : the Medical Assistance Fund in Selingué Indigent defined as people without means of payment when they are sick Fund gathering resources from different partners (local authorities, external donors, the State) Social investigation achieved by the social services associated with the health care unit Decision by an ad hoc committee : payment for the indigent or loan (that is to be reimbursed) Results : less than 2% of the users of the health care centre are concerned ; the rate of reimbursement is more than 50%

9. A. Letourmy, CERMES- CNRS, Antwerp, 18 December 2003 2-4 General solution : a National Medical assistance fund Definition of indigent people : non statutory but pragmatic, depending upon the situation Institutions providing the resources : the decentralized authorities, the State, the insurance schemes Decentralized management, but general rules concerning the covered basket of services, the way of determining the exempted people, etc. National evaluation and control Questions, debates and conflicts : the institutional nature of local management (local board of the fund, local authority, mixed organisation) ; the repartition of the funding between the State, the decentralized authorities and the others.

10. A. Letourmy, CERMES- CNRS, Antwerp, 18 December 2003 3-1 Poor people as a vulnerable population The promotion of health micro insurance and especially mutual health societies The limit : the payment of the contribution Insurance excludes very poor people Is it possible for poor people to get an access to health insurance ?

11. A. Letourmy, CERMES- CNRS, Antwerp, 18 December 2003 3-2 Local solutions 1st example (Nongon) : collective payment of the contributions based on the crop of cotton 2nd example (rural MHS in Borgou, Benin)) : automatic inclusion of poor people in some villages where MHS are implemented 3rd example : the linkage of micro insurance and micro finance (or micro enterprises) makes easier the access to health insurance (ex : Koulikoro and Kènèya So)

12. A. Letourmy, CERMES- CNRS, Antwerp, 18 December 2003 3-3 Limits to local solutions The community level is the adequate level for the identification of indigent people and the expression of traditional solidarity. It is inadequate in terms of risk pooling MHS are attracting people with resources higher than the resources of the population : are these people ready to give a subsidy to the poorest ?

13. A. Letourmy, CERMES- CNRS, Antwerp, 18 December 2003 3-4 General (virtual) solutions Universal coverage : questions to national projects (Ivory Coast, Gabon, Kenya) IC : differences between the rural scheme and the urban scheme Allowances to mutual health societies Individualized payment of the contributions to the MHS for poor families

14. A. Letourmy, CERMES- CNRS, Antwerp, 18 December 2003 Conclusion : problems and questions Definition of indigents : differences between the 2 kinds of solutions (direct access and insurance) Advantages of insurance ? Differences between poor and ultra poor people The role of the supply of health services