Atelier sur «l Équité dans la couverture maladie universelle: comment atteindre les plus pauvres»

Atelier sur «l Équité dans la couverture maladie universelle: comment atteindre les plus pauvres» Workshop on Equity in universal health coverage: how to reach the poorest Country Briefs Fiches profiles de pays Hosted by: The Harmonization for Health in Africa (HHA) Financial Access to Health Services Community of Practice (FAHS CoP) in collaboration with The Expanding Coverage Track of the Joint Learning Network for Universal Health Coverage (JLN) and the Moroccan government 24 th 27 th September 2012 Hotel Kenzi Farah, Marrakesh, Morocco

Benin Improving Health Care Coverage for the Poorest: BENIN Country Context and Summary of Program(s) In order to expand protection to all social categories, the Government of Benin introduced universal health coverage reforms in 2008 aimed at the entire population. A Plan National de Développement du Secteur de la Santé (PNDS) and a Plan Stratégique de Développement des Mutuelles de Santé (2009 2013) were introduced. A pilot phase of the Régime d Assurance Maladie Universelle (RAMU) was implemented in December 2011 by the Inter ministerial Technical Committee, supported by the Minister of Health. The RAMU was launched nationwide on 1 st April 2012. Until then, under 10% of the population was protected through public, private or mutuelles health insurance schemes, and under 4% of indigents (20,000 out of 455,000) were covered through a Fonds Solidaire des Indigents (FSI), introduced in 2005 to finance health user fee exemptions. Source: World Development Indicators Program Name Régime d Assurance Maladie Universelle (RAMU) Fonds Sanitaire des Indigents (Health Equity Fund for indigents) Date launched 19 th December 2011 2000, reforms in 2005 Stage Nationwide expansion from 1 st April 2012 Existing Target Population Place of Operation Services Covered / Benefits Package Mechanism to Reach the Poorest Methods to Identify the Poorest Program Coverage Managing Institutions / Roles Funding Sources and Amounts All populations National General and specialized consultations, nursing care, medicines, laboratory exams, imaging, diagnostic medicine, hospitalization and surgery, pre and postnatal consultations, deliveries and c sections, emergency transportation Exemptions Identification of beneficiaries is conducted at the community level No data available Ministry of Health / ANAM (Agence Nationale de l Assurance Maladie) FASNAS a, state, local authorities, technical and financial partners (Coopération Française, Coopération Suisse, ILO, WHO, World Bank), membership contributions (5% income for formal sector workers; 1,750 to 15,000 FCFA monthly contributions for informal sector workers, according to their activity sector; no membership fees for indigents) Indigents (5% of the population, around 455,000 inhabitants) and under 5 year olds National Free c sections, preventive medicine (vaccinations, anti parasitic treatments, vitamin A supplements, distribution of treated antimosquito nets), chronic disease treatment (HIV/AIDS, TB), medicines and food Exemptions Identification and validation mechanisms are conducted by Comités Locaux d Identification Villageois des Indigents (CLIVI), according to criteria adapted to each context Less than 20,000 beneficiaries Ministry of Health Total Population (millions) 9.1 (2011) OOP health expenditure (% of total expenditure) Life Expectancy at birth (years, both sexes) Infant Mortality (per 1,000 births) Maternal Mortality (per 100,000 births) Hospital beds (per 1,000 people) Public health expenditure (% of total health expenditure) Total health expenditure (% GDP) 46.8% (2010) 55.6 (2010) 73.2 (2010) 350 (2010) 0.5 (2010) 49.5% (2010) 4.1% (2010) State ( Secours et aides sociales budget, 1.25 billion FCFA) a Fonds d Appui à la Solidarité National et à l Action Sociale

Highlights of Programs to Reach the Poorest Achievements/Successes Active identification of indigents. Through the Comités Locaux d Identification Villageois des Indigents (CLIVI, community based organizations). CLIVI coordinate with the Projet d Appui à la Zone Sanitaire which processes applications through its Plateforme Société Civile et Santé (PSCS), made up of four facilitators spread over four communes. Facilitators accompany beneficiaries to a health center in their zone where indigents are given an identification card and benefit from free health services through the Fonds Sanitaire des Indigents (FSI). Biometric identification of the poorest. The FSI uses biometric tools to identify the poor and to secure a reliable database, thus ensuring that only eligible persons benefit from fee exemptions. RAMU has received strong political backing. The President of the Republic has been personally involved and monitors the program, and several development partners have demonstrated support (ILO, WHO, World Bank, Coopération Suisse, Coopération Française). A technical committee has been established to ensure adequate health service infrastructure and equipment. An information, education and communication campaign has also been conducted to sensitize the public. Lessons Learned/Challenges The number of beneficiaries of the FSI is still low (4% of indigents). Difficulties linked to active identification of indigents. Facilitators and health agents do not systematically operate according to established identification criteria or with the involvement of local authorities. Beneficiaries are not only the very poor. The term indigent is often misinterpreted and includes individuals who are able to pay minimum health service fees. Public resources are therefore spent on non eligible persons ( leakages in enrollment ). Limited strategic steering of the RAMU. The legal issues, benefits package and payment mechanisms of the RAMU still need to be resolved. There remains a lack of inter sectoral coordination and insufficient involvement of all stakeholders (CBHI, healthcare providers, local government units). Way Forward Efforts to help provide uniform criteria to identify eligible households are underway. The World Bank will provide support to the Projet de Renforcement de la Performance du Système de Santé (PRPSS) to strengthen the health program at the community level and improve methodology to register households and better identify eligible segments of the population. Human resources must be trained to implement adequate technical platforms to handle eligible cases. The FSI has received the support of Performance Based Financing (PBF), which enables the evaluation of the quality of services provided to beneficiaries. The tools developed in the context of PBF will be transferred to the RAMU. Actuarial and costing studies were supposed to be conducted during the second semester of 2012 in view of progressivelydefiningtechnicalandfinancialoptionsover the next ten years of program implementation. References Mathauer I, Ntamwishimiro Soumare A, Semegan B, Analyse du financement de la santé et réflexions sur le régime d assurance maladie universelle au Bénin, Rapport technique d une mission d appui de l OMS, décembre 2010. Plan National de Développement Sanitaire, 2009 2018, Ministère de la Santé. Tchibozo H, Atemenou A, Edon E, Ayi M, et al., Processus de mise en place d un Régime d Assurance Maladie Universelle (RAMU), Rapport d étape au 30 novembre 2011. Les Béninois disposent désormais d un Régime d Assurance Maladie Universelle (RAMU), Le RAMU a été officiellement lancé par le Chef d Etat, Dr Thomas Boni YAYI, Organisation Mondiale de la Santé, Bureau Pays du Bénin, Communiqué de Presse n 30 du 21/12/2011. World Health Organization, Providing for Health, Benin, P4H coordination desk mission report, February 2012, http://www.who.int/providingforhealth/countries/2012_02_17_cm BeninFebmissionreport.pdf (accessed 11th July 2012).

Improving Health Care Coverage for the Poorest: ETHIOPIA Country Context and Summary of Program(s) Introduced in 1998, Ethiopia s health care financing strategy provides a framework for reforms aimed at mobilizing resources, ensuring efficient and equitable use, and improving overall quality and delivery of health services. The strategy supports reforms that include revenue retention and use at the health facility level, systematizing a fee waiver system to reduce financial barriers for the poor and standardizing fee exemptions to encourage uptake of preventive health services. These reforms were first introduced in the four largest regions (Amhara, Oromia and Southern Nations, Nationalities and Peoples Region (SNNP)) of the country, and are now being widely scaled up. Second tier reform activities include implementation of a social health insurance scheme (SHI) for the formal sector and community based insurance schemes (CBHI) for the informal sector. The SHI program is expected to cover approximately 12% of the population. The CBHI scheme is intended to serve the informal sector in Ethiopia, which accounts for 89% of the total population. Program Name Fee Waivers Exemptions Community Based Health Insurance Year Launched 2007 2007 2011 Stage Existing Existing Pilot, scale up Target Population The fee waiver program is intended to reach populations who are living below the dollar a day poverty line (approximately 29% of the population). All populations Indigent populations Place of Operation Mechanism to Reach the Poorest Methods to Identify the Poorest Program Coverage Services Covered/ Benefits Package Implementing Partners and Roles Implementation in all regions except Afar and Somali Implementation in all regions CBHI schemes are currently being piloted in 13 woredas or districts in the Amhara, Oromia, Southern Nations, Nationalities and Peoples (SNNP) and Tigray regions. The districts were selected on the basis of readiness of health facilities and represent both resource poor and better off districts. Fee Waiver Exemption General subsidy and full coverage of premiums for selected indigents Community based targeting Everyone is eligible regardless of income Community based targeting Information about program coverage is not compiled at the national level. Regional governments track their own coverage rates. There is no reporting of program coverage at the national level. Separate programs HIV, TB, ANC, PNC, Delivery, FP, Fistula, etc., track their own coverage levels. The target is to cover 50% of the total informal sector population in 2015. In the pilot program being implemented in the 13 districts, 125,142 heads of households (99,565 paying and 25,577 non paying) became beneficiaries in the one year pilot period, i.e. nearly 42% of the total heads of households of the pilot districts. Inpatient and outpatient Inpatient and outpatient Inpatient and outpatient MoH: Outline strategy Regional government: Outline legal framework to implement strategy, assign resources, supervise implementation District governments: Secure health facilities that will implement program Partners: Technical assistance MoH: Outline strategy, secure financial resources Regional government: Outline legal framework to implement strategy, assign resources, supervise implementation Districts governments: Secure health facilities, human resources and some financial resources Partners: Provision of supplies, funds, technical assistance Total Population (millions) 84.7 (2011) OOP health expenditure (% of total expenditure) Life Expectancy at birth (years, both sexes) Infant Mortality (per 1,000 births) Maternal Mortality (per 100,000 births) Hospital beds (per 1,000 people) Public health expenditure (% total health expenditure) Total health expenditure (% GDP) Source: World Development Indicators Funding Sources Government budget Government budget and donors Government budget Ethiopia 37.2 (2010) 58.7 (2010) 67.8 (2010) 350 (2010) 0.2 (2008) 53.5% (2010) 4.9% (2010) MoH: Outline strategy, provide general subsidy Regional government: Outline legal framework for implementing strategy, assign resources, supervise implementation District governments: Assign resources, implement program Partners: Technical assistance

Highlights of Programs to Reach the Poorest Achievements/Successes The fee waiver and exemption programs are two components of a broader Health Care Financing Reform (HCF) package. Ethiopia s HCF reforms include: First generation supply side reforms such as revenue retention and utilization, user fee setting and revision, fee waiver and exemption, supporting health facility autonomy through the establishment of governing bodies, outsourcing of non clinical services in public hospitals and establishing private wings in public hospitals. Second generation demand side health insurance reforms (Social Health Insurance, Community Based Health insurance and Private Health Insurance) Fee Waivers: A mechanism for providing services free of charge to Ethiopia s poor. Eligible beneficiaries are screened and identified through community participation. Selected beneficiaries are given a certificate entitling them to free health care services. The participatory community targeting approach has been a successful mechanism for identifying beneficiary populations in Ethiopia, where the majority of the economy is informal. Prior to the reform there was no systematic way of identifying beneficiaries. Performance varies from district to district, but overall the fee waiver system has received political support. Districts have a budget allocation for reimbursing providers for fee waiver beneficiaries. This has been important in the face of competing priorities and budget shortages. In some districts where food aid is combined with free medical care through the fee waiver system, beneficiaries donate their labor to environmental protection activities like terracing, farming, afforestation, labor based rural road construction, among others, contributing to local development activities. As an example, the Amhara region is the second most highly populated region in Ethiopia, where nearly 19 million people live within 157,347 sq. km. 13.1% of its population lives in urban areas and the remaining 86.9% in rural areas. The region is divided in to 10 zones, three City Administrations, 167 Districts, 3411 Kebeles (3113 rural and 318 urban). There are 17 public hospitals and 761 health centers (HC). All of the hospitals and 504 HCs are implementing health care financing reforms including fee waivers and exemptions. The remaining health centers are expected to introduce financing reforms in the next two years. Exemption Program: The exemption program requires public health facilities to post a list of exempted services in their waiting areas. Facilities are responsible for creating awareness through postings, broadcasts and other forms of media. Exempted services are almost the same across all regions and include family planning, delivery, pre and postnatal care, TB, VCT, PMTCT, leprosy and ART services and programs. Donor contributions make up 40% of the health budget with the majority going to exempted services. Exempted services covered by donors include the Expanded Program on Immunization, tetanus toxoid vaccine, family planning commodities, ART drugs and test kits, and anti malarial drugs. The government share of the budget covers staff salary, prenatal and antenatal care, delivery, and cost sharing of supplies from UN sources. The exempted services program also benefits from political support and the support of the donor and NGO community. Lessons Learned/Challenges Reaching beneficiary populations in remote areas for identification and enrollment (issuing ID cards/certificates) is a major challenge. It is difficult to determine how long households remain in poverty. Verification/re identification is a cumbersome process. There is no consensus on how this should be done, some regions issue ID cards every three years, others issue ID cards every year. The capacity of lower level government branches and community empowerment to perform this function is weak. In a large and populous country like Ethiopia, it is hard to verify, appraise and obtain approval and endorsement of the proposed beneficiaries from many lower government administrative structures/units and villages. Transport and accommodation costs are an additional cost for fee waiver beneficiaries who are sent to referral hospitals located in big urban centers where the cost of living is expensive. A lack of essential drugs, supplies, medical equipment, surgeons and health workers has hampered the delivery of quality services for the poor at public facilities. Funding shortages in the government s budget limit the enrollment of additional beneficiaries and the availability of resources for reimbursement of health care facilities. Budget shortages also compromise incentive programs for specialists and other key health care professionals, and as a result some services are not delivered or sustained. The government s budgeting system does not track resources by type of intervention, but uses line item budgeting (e.g. salaries, drugs, equipment, etc.). Many of the budget items reflect cross cutting costs, as such the budget allocation for exemptions, fee waivers and community based health insurance is not directly known. Fee waiver beneficiaries cannot access services at private facilities with higher prices which are beyond the capacity of the government to reimburse. There is a lack of clear guidance on whether to fully or partially charge for exempted services. Fee waiver beneficiaries follow a referral system to access care at secondary and tertiary levels, but grass roots level health facilities (health posts and health centers) located in remoteareas are not yet well equipped to follow this system. Way Forward Based on the pilot experience, CBHIs will be scaled up to cover 50% of the informal population by 2015. Regional and district authorities will cover premiums for indigent population through the CBHIs which are expected to reach 10% of the total population (approximately 8 million people). The federal government will provide a general subsidy to CBHI schemes that will be based on the number of registered household members, and that amounts to 25% of premiums collected from members. Implementation of the SHI scheme is expected to begin in the next few months. References Ethiopia Health Sector Financing Reform Midterm Project Evaluation, USAID, December 2011. Interview with Genet Anteneh Delele, Regional Director, USAID/Health Sector Financing Reform Project, Amhara and Benishangul Gumuz Regional Office, Bahir Dar, Ethiopia

Ghana Improving Health Care Coverage for the Poorest: GHANA Country Context and Summary of Program(s) In 2003, Ghana passed a Health Insurance Law and embarked on a process of developing and implementing a National Health Insurance Scheme(NHIS)to replace out of pocket fees at point of service. The National Health Insurance Authority (NHIA) was designated as the regulator and supervisor of the NHIS and given the responsibility of managing the National Health Insurance Fund from which subsidies are paid to District Mutual Health Insurance Schemes. Operation of the scheme at the district level is by District Mutual Health Insurance Schemes (DMHISs). Service Provision within the NHIS is by the Ghana Health Service, faith based groups such as the Christian Health Association of Ghana and the private for profit sector. The NHIS is a voluntary scheme which provides coverage for both formal workers and the informal sector. It provides exemptions for pregnant women, the elderly, children under 18 and the indigent who NHIS defines by law, as persons with no income or other means of support or home. Total Population (millions) 24.9 (2011) OOP health expenditure (% of total expenditure) Life Expectancy at birth (years, both sexes) Infant Mortality (per 1,000 births) Maternal Mortality (per 100,000 births) Hospital beds (per 1,000 people) Public health expenditure (% of total health expenditure) Total health expenditure (% GDP) Source: World Development Indicators 26.9% (2010) 63.8 (2010) 50 (2010) 350 (2010) 0.9 (2011) 59.5% (2010) 5.2% (2010) Program Name National Health Insurance Scheme (NHIS) Year launched 2004 Stage Scale up Target Population Pregnant women, the elderly, children under 18 and the indigent defined by NHIS law as persons with no income or other means of support or home. Place of Operation National Mechanism to Reach Exemptions for the indigent and vulnerable groups the Poorest Methods to Identify the Poorest DMHISs are responsible for identification and enrollment. Though guidelines for identifying the poorest exist, mechanisms for identifying the poorest vary between DMHISs. Some DMHISs leverage community representatives, NGO s and other non state groups to identify and enroll the poorest. With the recent scale up of the Livelihood Empowerment Against Poverty (LEAP) program implemented by the Ministry of Employment and Social Welfare, the program is increasingly being used to enroll the poorest into the NHIS. Program Coverage 8,204,116 active members (33.3%) (2011) 313,578 indigents (3.8%) (2011) Services covered Benefits Package Coverage of 95% of health problems reported in Ghanaian health facilities. Includes: outpatient services, inpatient services, oral health, maternity care, emergency care Implementing Partners and Roles Funding Sources and Amounts Ministry of Health: Policy oversight National Health Insurance Authority: Regulator supervisor/fund manager District Mutual Health Insurance Schemes: Member enrollment/provider payment 72.7% 2.5% health insurance levy added to VAT 17.4% Contributions from formal sector workers to the Social Security and National Trust (SSNIT) 5.3% Interest on fund 4.5% Premium payments 0.1% Other income 0.03% Donor funding

Highlights of programs to Reach the Poorest Achievements/Successes NHIS policy allows indigents to enroll in the NHIS and access comprehensive care for free. Exemptions for the indigent cover the cost of premium and processing fees for enrolling in the NHIS. Once the indigent enroll, NHIS is structured such that comprehensive care is provided and no co payments or top up payments are to be expected. Automatic eligibility for premium exemptions for beneficiaries of social protection program. Ministry of Health policy confers automatic eligibility for premium exemption for any beneficiary of the LEAP program. The LEAP program was initiated in 2008 and now operates in 20 districts and supports 68,000 households. The LEAP program is the leading poverty targeting program in the country and uses a proxy means test and community based identification to identify the poorest. The Ministry of Health policy has practically broadened exemptions under the NHIS to the extreme poor who are the focus of the LEAP program. This effectively puts to rest the dilemma of whether the indigent are synonymous with the extreme poor. Identification of exempt groups through NGOs and other non state actors. Some District Mutual Health Insurance Schemes obtain lists of exempted populations through NGOs and other non state actors. This allows the schemes to leverage the efforts of these organizations to identify the extreme poor and obtain the proof required to grant exemptions. Lessons Learned / Challenges Strict requirements for exemptions are severely limiting. TheNHISisoperatedbydistrict levelmutualhealth Insurance Schemes (DMHISs) which use community agents to identify and enroll new beneficiaries including the poor and indigent. During the initial implementation phase of the NHIS, agents of DMHISs used a community based identification system to enroll beneficiaries. In the course of implementation, it was observed that there were significant leakages in the enrollment process. In response, the NHIA began requiring that DMHISs submit proof for exemptions granted and utilized the audit process to enforce this. However, documentation of poverty, especially where no well developed tools for identification exist is difficult, if not impossible. This has led to the unintended exclusion of many of the extreme poor from exemption (under coverage). The NHIS law s restrictive definition of indigent further restricts the Schemes ability to identify and enroll the extreme poor. In practice, the NHIA would like to broaden exemptions to cover all the extreme poor those considered to be in the bottom quintile or 20%. However, due to the law s restrictive definition of indigent and the low scale of the LEAP program, there are many extreme poor who do not qualify for exemptions because they do not meet criteria required to be classified as indigent or are yet to be covered by the LEAP program. District schemes are not incentivized to enroll the extreme poor. DMHISs rely on the revenue they collect from premiums and processing fees to cover their operating costs. There is therefore little incentive for the schemes to identify the extreme poor because exempt persons do not pay these premiums and processing fees. Moreover, agents do not earn any commissions when they enroll the extreme poor and are therefore not motivated to identify and enroll them. The lack of an accountability mechanism in place for schemes to identify and enroll the extreme poor further aggravates their willingness and ability to enroll this category of persons. Barriers to healthcare remain for the indigent. In practice, even where the extreme poor are covered through exemptions, they have had significant problems navigating the healthcare provision system due to their limited knowledge of the available benefit package. In some cases exempt beneficiaries have been required to make top up payments or have incurred other OOP expenditures for accessing healthcare. Way Forward Working towards a Common National Targeting Mechanism. The NHIA is currently working with the LEAP program and other stakeholders to develop a national common targeting mechanism based on the process developed by the LEAP program for identifying the poor. The success of this approach will be contingent on resource availability for the LEAP program. As an additional next step, the NHIS law should institutionalize the use of the Common National Targeting Mechanism. In September 2012 parliament introduced an amendment that will require the NHIA to report on health equity, including utilization of services by the poor, in the NHIS. References Data and information provided by Mr. Nat Otoo, Director of Administration and General Counsel, National Health Insurance Authority, Ghana UNICEF, Social Protection and Children: Opportunities and Challenges in Ghana. 2009, Accra: UNICEF, ODI.

Improving Health Care Coverage for the Poorest: KENYA Country Context and Summary of Programs The National Hospital Insurance Fund (NHIF) is the primary provider of health insurance in Kenya with a mandate to enable all Kenyans to access quality and affordable health services. NHIF requires compulsory membership for all salaried employees, with premium contributions automatically deducted through payroll. Contributions are calculated on a graduated scale based on income, with a majority contributing between KES 30 to KES 320 per month. For the self employed and others in the informal sector, membership is contributory and is available for a fixed premium of 160 KES per month. While Kenya has achieved high levels of coverage of the formal sector, coverage of the informal sector has proven to be more challenging. Total membership in NHIF rose from about 206,000 in 1998 to 1,372,000 in 2006. As of 2011, NHIF has 2.7 million contributors, of which 2.1 million are employed in the formal sector. Approximately 88% of the people with insurance in Kenya are insured by NHIF. Currently only about 25% of the poor have medical coverage. NHIF is embarking on a subsidy program to improve access to health care for poor populations. Program Name Fee Waiver and Exemption Program Sponsored Program Health Insurance Subsidy Program (HISP) Year Launched Late 1990 2010 TBD, project is in final design stage Stage Existing Existing Project is in design stage Target Population Those who are marginalized and face financial barriers to accessing health care services. The program targets population groups that include children under 5 years, HIV/AIDS patients, patients with mental disabilities, and services such as antenatal and postnatal care, and family planning. Indigent population Indigent population. Based on World Bank definition. Place of Operation National level National level Regions to be selected based on poverty indices Program Affiliation Mechanism to Reach the Poorest MoH program introduced to reduce the adverse effect of user fees on the poor Stand alone Stand alone pilot Exemptions and fee waivers Sponsorships to cover premiums A fund to subsidize premiums for the poorest Program Coverage Not available Approximately 3500 Not yet implemented Services Covered/ In patient Benefits Package Methods to Identify the Poorest Managing Institutions and Roles Geographic targeting and proxy means testing Implementing Agency: MoH Other Partners: USAID, Elizabeth Glaser Foundation, Aphiaplus, among others In patient. Enhanced coverage including outpatient cover is provided at a premium rate that is negotiated between the donor/sponsor and NHIF. Geographic targeting and proxy means testing Implementing Agency: NHIF Total Population 41.6 mill. (2011) OOP health expenditure (% of total expenditure) Life Expectancy at birth (years, both sexes) Infant Mortality (per 1,000 births) Maternal Mortality (per 100,000 births) Hospital beds (per 1,000 people) Public health expenditure (% of total health expenditure) Total health expenditure (% GDP) Kenya Source: World Development Indicators 42.7 (2010) 56.5 (2010) 55.1 (2010) 360 (2010) 1.4 (2010) 44.3% (2010) 4.8% (2010) Outpatient and in patient with a focus on increasing access to primary health care Geographic targeting and proxy means testing Implementing Agency: NHIF Donor Partners: Rockefeller Foundation Funding Sources and Amounts MoH subsidizes all services provided in public health facilities, including fee waivers and exemptions. Donors, private corporations, religious institutions, philanthropic individuals NGOs. As of August 30, 2012, the program had raised (KSH) 43, 721, 793. Rockefeller Foundation (KSH) 17, 000, 000

Highlights of Programs to Reach the Poorest Achievements/Successes NHIF is currently piloting a new approach to reaching the poorest. Kenya s fee waiver and exemption program has been ineffective in addressing issues related to health care access for the poorest. To extend coverage to the indigent population, NHIF introduced the Sponsored Program in 2010. Through this program, NHIF mobilizes donor resources to finance health insurance for indigents including orphans and vulnerable children, poor older persons, persons with disabilities and destitute families. To date, sponsorships have enabled approximately 3500 indigent beneficiaries to access inpatient services at all NHIF accredited facilities. The Health Insurance Subsidy Program is in the final design phase, there are no reported results as of yet. Lessons Learned / Challenges Fee waiver and exemption programs. The fee waiver and exemption program was established to mitigate the negative impact of user fees introduced in the late 1980 s, on access to health care by the poor. The program has been regarded as a cumbersome and ineffective mechanism for improving access to health care for the poorest, marred by political interference and leakages to non poor populations. The program offers very few incentives for providers. Payments are delayed and providers are not compensated for revenues foregone due to waivers and exemptions. There is very little awareness about exempted services and waivers among beneficiary populations and health staff, thus uptake has been low. The program lacks clear criteria for identifying and defining eligible beneficiaries. Because the beneficiary population is poorly defined, it is difficult to estimate the scope of the program, both in terms of the number of beneficiaries and the costs to individual providers. 10/20 policy: First introduced in 1989 but slow to take off due to implementation and design challenges, the 10/20 policy was re introduced in 2004. The policy mandates free outpatient primary health care at dispensaries and health centers for all citizens, except for a minimum registration fee of Kenya Shillings (KES) 10 at dispensaries and 20 at health centers (approximately USD 0.2 and 0.3). Under this policy, children under the age of 5 and specific health conditions such as Malaria and Tuberculosis are exempted from payment. In 2007 all fees for deliveries in public health facilities were abolished. Adherence to the 10/20 policy has been poor; facilities have experienced a loss in revenue, drug shortages, and there has been lack of clarity in exemption criteria. Beneficiary communities have very little understanding of the policy. Payments are still required for the majority of services, even for vulnerable groups. The Health Sector Services Fund (HSSF) was established in 2010 to address the lack of adequate resources at the health facility level resulting in poorly maintained equipment and infrastructure, staff shortages, drug shortages and poor quality of care. Prior to HSSF, health facilities relied on government revenue, user fees, NHIF, private and employer sponsored health plans and individual resources. Direct funding to health facilities has the potential to reduce the payments that are still required for many services if exemption criteria and adherence to the 10/20 policy are improved. Way Forward NHIF is designing a Health Insurance Subsidy Program (HISP) to expand coverage to indigent populations comprising 20% of Kenya s overall population. The program is in its final design stage, and is expected torolloutsoonasapilotprogramwithsupportfromtherockefeller Foundation. The pilot will be implemented in areas that are identified as high poverty areas. NHIF is working closely with the Kenya National Bureau of Statistics (KNBS) to identify and validate target regions and populations. Potential pilot sites based on past poverty indices include the Coastal, Nairobi and Western regions. The sample size has not yet been scientifically determined by the National Bureau of Statistics. The initial plan was to leverage existing Social Protection Programs (SPP) being implemented by the Ministry of Gender, Children and Social Development. This is being re examined as it has been argued that the results of the study would be skewed towards target populations that include Orphans and Other Vulnerable Children (OVC), Older Persons, and Persons with Severe Disability (PWD). In addition, the sample derived from the SPPs, would not be large enough to provide a true representation of the entire population. Lessons drawn from the experience of the pilot program will be used to generate evidence to inform policy and ensure the sustainability of a MoH supported subsidy program. HISP will provide the foundation for the formulation of a Health Care Financing Strategy in Kenya. References Joint Learning Network for Universal Health Coverage, Kenya: National Hospital Insurance Fund Case Study Interview with Juliet Maara, Senior Program Officer, NHIF

Mali Improving Health Care Coverage for the Poorest: MALI Country Context and Summary of Program(s) Between 2005 and 2009, the government of Mali engaged in a process to extend health coverage to the entire population. Beneficiaries are covered through three systems: Mutuelles (community based health insurance), Assurance Médicale Obligatoire (AMO, mandatory health insurance) or the Régime d Assistance Médicale (RAMED). In 2012, all three systems cover around 7% of the population (1,059,587 persons). Mutuelles have been a component of the health financing system in Mali for over 20 years, but in 2010 covered only 3.3% of the population. They were relaunched in 2011 to include all informal and agricultural sectors (78% of the population) and are overseen by the Union Technique de la Mutualité (UTM). The targeted number of beneficiaries in the first phase is 1.2 million people (40% of the target population in the three regions, Sikasso, Ségou and Mopti). By the end of December 2011, health Mutuelles registered 161,369 new members (for a total of 489,451 beneficiaries). AMO was launched in 2011 in five regions, through 23 pilot Mutuelles, to cover government and formal sector employees (17% of the population) who contribute a percentage of their salary for medical insurance. By the end of 2011, 514,475 members were registered. RAMED is a non contributory health insurance scheme, introduced in 2011 to ensure health care for the poorest (5% of the population, i.e. 750,000 inhabitants). Under RAMED, indigents will be insured for one year with the possibility to renew each year. RAMED provides the right to direct and full payment of the costs of care. By 2014, coverage rates are expected to reach 40%, all schemes combined. Total Population (millions) 15.84 (2011) OOP health expenditure (% of total expenditure) Life Expectancy at birth (years, both sexes) Infant Mortality (per 1,000 births) Maternal Mortality (per 100,000 births) Hospital beds (per 1,000 people) Public health expenditure (% of total health expenditure) Total health expenditure (% GDP) Source: World Development Indicators 53.2% (2010) 51.0 (2010) 99.2 (2010) 540 (2010) 0.1 (2010) 46.6% (2010) 5% (2010) Program Name RAMED (Régime d Assistance Médicale) Date launched 2011 Stage Pilot phase Target Population Indigents (5% of the country s population, approximately 750,000 inhabitants) (14 21 year olds in education, handicapped, orphans, pensioners, isolated/homeless persons) Place of Operation District of Bamako and circle of Kati Services Covered / Benefits Package Ambulatory care, hospitalization, medicines, biological exams, imaging, maternity The RAMED does not cover medicines for certain illnesses, sickness prevention or patient follow up. Mechanism to Reach the Poorest Methods to Identify the Poorest Exemptions Social services conduct enquiries to identify indigents: means and proxy means testing, family member dependence, personal and family medical histories Documents are transferred to the ANAM which processes applications for enrollment. Once applicants are identified, they receive a certificate of indigence with which they can be registered upon their next visit to a health center, where they are issued an insurance card (valid for one year, renewable) and a medical records book. Program Coverage 1,015 beneficiaries (0,02%) Managing Institutions / Roles Funding Sources and Amounts ANAM (Agence Nationale d Assistance Médicale) management agency of RAMED. Collects funds, processes applications, registers beneficiaries, issues cards to eligible beneficiaries. Cover 100% health expenses for the poorest. MDSSPA (Ministère du Développement Social et de la Solidarité et des Personnes Agées) is in charge of identifying target populations, through local agencies and community organizations. Government 65% (1 billion FCFA) Regional authorities 35% (so far no funds have been collected) 35% overall funds have been allocated.

Highlights of Programs to Reach the Poorest Achievements/Successes A national communication strategy was implemented in 2011 to inform beneficiaries and health workers about RAMED. The agency Bintily Communications was recruited to produce communication banners in six communes of Bamako and campaigns on national television. Identification of indigents is conducted under the responsibility of community authorities, according to the eligibility criteria imposed by local community commissions. These committees include a guidance counselor and mayor, physician or head of social development services. The ANAM began talks with community authorities at the beginning of 2012 regarding the methods of identification and registration of the poorest. An information system (ESQUIF) is being implemented to manage ANAM. Human resources are being recruited and trained to run these information systems to manage data collection, identification, registration, monitoring and evaluation. The State has been successful in mobilizing funds to implement the RAMED. Lessons Learned / Challenges In practice, the RAMED is confronted with financial and technical constraints. ANAM is experiencing difficulties in accessing resources from territorial collectivities in order to finance RAMED (703 communities, expected to contribute 365 million FCFA to ANAM, have not collected their share of funds). 47,982 indigents have not been identified due to insufficient funds, lack of participation from regional and local authorities, insufficient communication and sensitization about the program, the lack of civil status for indigents, the political and security crisis, fraud, with the overall consequence being slow implementation of the RAMED. Monitoring and evaluation of service utilization by beneficiaries is impeded by the absence of records kept on indigentsat the community level and by the lack of data collected and retained by service providers. Ongoing large scale implementation, improving coordination between three health coverage systems. The near simultaneous implementation of three health coverage systems is a major challenge. The ANAM is putting into place adequate information, resource management, purchasing, monitoring and evaluation systems, an indigent census and a trained workforce to carry out data collection. Way Forward Revisions are ongoing on the final legal texts relating to the implementation of RAMED (review of benefit packages, financial contributions of territorial and local collectivities, diversification of financial sources). Increased sensitization and improved communication on health reforms and the RAMED are being worked on to increase awareness among all stakeholders. Innovative funding mechanisms for the RAMED are being explored and created. References African Development Fund (ADF), Second Growth and Poverty Reduction Strategy Support Programme (GPRSSP II), Appraisal report, 28 th June 2011, http://www.afdb.org/fileadmin/uploads/afdb/documents/project and Operations/MALI%20 %20PASCRP%20II%20 %20Anglais.pdf (accessed 24 th August 2012). Unpublished data from the Ministère de l Action Humanitaire, de la Solidarité et des Personnes Agées et de l Agence Nationale d Assistance Médicale, September 2012.

Nigeria Improving Health Care Coverage for the Poorest: NIGERIA Country Context and Summary of Program(s) As a part of the effort to strengthen the national health system, Nigeria adopted the National Health Sector Reform (NHSR) program in 2006. The program includes the implementation of a re designed National Health Insurance System (NHIS), first established in 1999. NHIS has developed several programs to ensure coverage of the different socio economic groups in the formal and informal sectors: public sector social health insurance (SHI) and community based health insurance programs (CBHI). The public sector social health insurance program targets employees in the federal government, while CBHIs target the self employed and rural dwellers. About 5 million people are enrolled in NHIS programs, representing approximately 3% of the population. Typically, user charges are associated with all government provided health services. Total Population (millions) 162.5 (2011) OOP health expenditure (% of total expenditure) Life Expectancy at birth (years, both sexes) Infant Mortality (per 1,000 births) Maternal Mortality (per 100,000 births) Hospital beds (per 1,000 people) Public health expenditure (% of total health expenditure) Source: World Development Indicators 59.2 (2010) 51.4 (2010) 88.4 (2010) 630 (2010) 0.5 (2004) 37.9% (2010) Total health expenditure (% GDP) 5.1% (2010) Program Name National Health Insurance Scheme MDGs Maternal and Child Health Project (NHIS MDG/MCH Project) Year Launched Phase 1 2008, Phase 2 2009 Stage Phase 1 Pilot, Phase 2 Expansion Target Population Pregnant mothers and children under 5 Place of Operation Phase 1: Sokoto, Niger, Gombe, Oyo, Imo and Bayelsa. Phase 2: Katsina, Jigawa, Yobe, Bauchi, Ondo, Cross River, making a total of 12 states out of Nigeria s 36 states Mechanism to Reach the Poorest Methods to Identify the Poorest Fee waivers Geographic targeting based on maternal and child health indicators. States with the worst indicators were selected for participation in the program. Program Coverage As of March 2011, 1.6 million mothers and children have been reached through Phase 1 and Phase 2. Services covered / Benefits Package The health service package covers primary care for all enrolled children and primary plus secondary care for all enrolled pregnant women. Children may be enrolled from birth until age five, while women may be enrolled from the moment their pregnancy is confirmed to six weeks after childbirth. Implementing Partners and Roles National Health Insurance Scheme (NHIS): Implementing Agency Health Maintenance Organizations (HMO), States and Local Government Areas (LGA), enrollment and registration: Implementing Partners Funding Sources and Amounts Debt Relief Gains (DRG) through the Office of the Senior Special Assistant to the President on MDGs (O SSAP/MDGs) and counterpart funding from benefiting states. Approximately US $33 million for Phase 1 and $28 million for Phase 2.

Program Highlights Achievements/Successes The NHIS MDG/MCH Project addresses Nigeria s critical problem of poor access to health care services for pregnant women and children under 5. With funding from a conditional grant under the MDG program, the project targeted pregnant women and children under 5 in select communities across the six geo political zones of Nigeria using a fee exemption scheme. Participating states were selected on the basis of maternal and child health indicators. Priority was given to the poorest states with the worst indicators. Public facilities were given a much needed funding boost. The program focused on encouraging participation and accreditation of public primary health care facilities over private facilities in the local government areas of the selected states. Several of these facilities were reported to be severely under utilized and even abandoned before the start of the project. Capitation payments were made directly to health facilities. Facilities were able to keep a portion of the capitation payment while passing the rest on to providers. Fees collected from capitation payments were used by facilities to renovate and improve overall infrastructure. A strong monitoring and evaluation component contributed to the success of the program. Each of the participating states had a program implementation team. From the outset, program activities were monitored on a monthly basis. Representatives of participating states carried out visits to facilities every two weeks to assess the progress of the program. Once the program was successfully established, state implementation teams carried out monitoring activities on a quarterly basis. Enrollee registration was carried out at multiple levels (facility, town halls, markets ) enabling large numbers of enrollees to be captured. Initially, pregnant women and children under 5 could only enroll at the facility level. Registration sites were expanded to improve community participation and involvement, and encourage enrollment within the participating states. The program relied on strong public private partnerships involving a network of HMOs (private organizations) and private health care facilities as important stakeholders in enrollment and service delivery. Fund management was decentralized to the health facilities providing services to participants. The funds were used for service related commodities only (drugs, consumables, health workers, facility improvement). Lessons Learned / Challenges The main challenge the program faces is that of financial sustainability. The project was established as a quick win program, funded by debt relief funds. There is uncertainty about how long current funds will last. Further, in the interim there is no legal structure in place to ensure any other source of funding. The availability of health facilities that are well equipped to provide quality care remains an issue. The terrain in some areas has made it difficult to reach and enroll target populations. Way Forward The target in Nigeria is to achieve universal coverage by 2020. This is a challenging but achievable target. The community based social health insurance (CBHI) program currently in pilot phase in two states targets the rural poor and has a subsidy component for pregnant mothers and children under 5. The subsidy program will form the Vulnerable Groups Fund (a Health Equity Fund) and will be financed directly by NHIS from revenue generated from investments of public sector insurance funds and other sources that are still being explored. The subsidy program will subsume the NHIS MDG/MCH Project. Nigeria is exploring innovative resource raising mechanisms for the health sector, including levies on mobile phones, airline tickets, alcohol and tobacco. References Joint Learning Network for Universal Health Coverage, Nigeria: National Health System Case Study The Costs and Benefits of a Maternal and Child Project in Nigeria, USAID, January 2010 Interview with Dr. Kabir Mustapha, Deputy General Manager & Acting General Manager, Standards & Quality Department, NHIS

Senegal Improving Health Care Coverage for the Poorest: SENEGAL Country Context and Summary of Program(s) Senegal introduced its first community based health insurance programs in the late 1980s. Around 200 mutuelles operate throughout the country, 48% of which are concentrated in Dakar and Thiès. Still, only 20% of the population is protected by health insurance and there is a lack of a formal health policy framework and coordination between the various interventions to cover the poorest (Institutions de Prévoyance Maladie (IPM), mutuelles, exemptions). A Fonds de Solidarité Nationale (Jappal Ma Japp) was introduced in 2002 to manage applications for exemptions and subsidies for accident and catastrophe victims and vulnerable populations. But with coverage rates being so low, the Senegalese government implemented a national health plan in 2009 (Plan National de Développement Sanitaire (PNDS) 2009 2018) in an effort to extend health insurance to all individuals. The government aims to cover 50% of the population by 2015. An equity fund was launched in 2012 to cover indigents and vulnerable groups, financed by the Belgian cooperation and managed by the Ministry of Health through the CAFSP (Cellule d Appui au Financement de la Santé et au Partenariat). The fund aims to assist the poorest in accessing health coverage through mutuelles and public private partnerships. Further reforms to reach the poorest include creating a Fonds National de Solidarité Santé (FNSS), restructuring IPMs, and extending health coverage through mutuelles. The FNSS, expected to be introduced in 2013, will ensure budgetary management and control, and administrative reinforcement to extend health insurance nationwide and ensure equity of access to health care for the poorest and most vulnerable. Source: World Development Indicators Program Name Equity fund Le Fonds de Solidarité Nationale, Jappal Ma Japp Date launched 2012 2002 Stage Pilot phase Existing Target Population Mother and child, indigent and vulnerable groups 215,760 indigent households Catastrophe, fire and calamity victims Place of 5 regions through 23 pilot mutuelles National Operation Services Covered /Benefits Package Primary Health Care, maternal health Health care services according to needs Mechanism to Reach the Poorest Methods to Identify the Poorest Exemptions Exemptions Mutuelles pre select indigents in cover zone, based on census data, registers, social service, community organizations and NGO lists. Lists of pre selected individuals are sent to regional authorities or social services, who coordinate investigations to validate lists. Local committees then selects the designated households for the mutuelles. The CAFSP and the mutuelle sign a financing agreement for the enrollment of the identified indigents. The CAFSP covers all administration, membership and health service fees. Program Coverage No data available 1,714 households (0.9% coverage) Managing Institutions and Roles Ministry of Health Ministry of Health since 2012 Funding Sources and Amounts Belgian Cooperation (650 million FCFA) Total Population (millions) 12.77 (2011) OOP health expenditure (% of total expenditure) Life Expectancy at birth (years, both sexes) Infant Mortality (per 1,000 births) Maternal Mortality (per 100,000 births) Hospital beds (per 1,000 people) Public health expenditure (% of total health expenditure) Total health expenditure (% GDP) 35% (2010) 59 (2010) 49.8 (2010) 370 (2010) 0.3 (2008) 55.5% (2010) 5.7% (2010) State (500 million FCFA), local collectivities and development partners.

Highlights of Programs to Reach the Poorest Achievements/Successes A strong political will to extend access to health services for the poorest has contributed towards recent advances in health systems reforms. The support from international organizations has been essential (Belgian Cooperation, Abt/USAID, ILO, WHO, P4H, World Bank, ADB) in implementing the new equity fund. No results are available yet, but by 2015, mutuelles aim to cover 405,000 vulnerable non fee paying members. Monitoring of identification rates, service utilization and community health reports are conducted every three months by the MSAS (Ministère de la Santé et de l'action Sociale), RM (Région Médicale) and mutuelles, as part of the pilot phase. Lessons Learned / Challenges Difficulties met in implementing the program include the identification of target populations, control of identity and eligibility, and coordination with other initiatives, sectors and ministries. Many potential beneficiaries are excluded due to heavy administration, service provider reticence and indigents lack of knowledge concerning the system. Challenges with financing for the program. 10% of health service revenues and 5% of benefits from the sale of drugs destined to be allocated to cover the poorest are not systematically transferred, mostly due to the mechanism s non mandatory nature. In practice, there remain barriers to care. Further challenges to reaching the poorest include illiteracy, poverty in rural areas, distance from health care facilities, sporadic health campaigns (maternal health, vaccination and screening days), and overall lack of incentives to adhere to health insurance. Way Forward The government seeks to strengthen coordination of health schemes for the poorest through harmonization of targeting strategies and tools. Building partnerships, improving intersectoral collaboration. By end 2012, the Global Health Initiative Interagency team will work with the Ministry of Health and other donor partners to develop a comprehensive community health policy to increase funding, ownership and oversight of community health programs. A feasibility study on the FNSS will be conducted on the extension of mutuelles nationwide and the integration of subsidy and exemption schemes within the mutuelles network to cover the poorest. References Boidin B, Alenda J, 33èmes journées des économistes de la santé français, «Extension de l assurance maladie et mutuelles de santé en Afrique : l expérience sénégalaise». Ministère de la Santé et de la Prévention, Cellule d appui au financement de la santé et au partenariat (CAFSP), Stratégie nationale d extension de la couverture du risque maladie des Sénégalais, feuille de route, Juin 2010.

Benin Améliorer la Couverture Sanitaire pour les Plus Pauvres: BENIN Contexte pays et Synthèse des programmes Dans l effort de protéger toutes les catégories sociales, en 2008 le gouvernement du Bénin s est penché sur le projet de mise en œuvre de la couverture universelle sanitaire pour la population entière. Un Plan National de Développement du Secteur de la Santé (PNDS) et un Plan Stratégique de Développement des Mutuelles de Santé (2009 2013) ont été lancés, et la phase pilote du Régime d Assurance Maladie Universelle (RAMU) fut lancée en décembre 2011 par un Comité Technique Interministériel, soutenu par le Ministère de la Santé. Le RAMU est devenu opérationnel dans tout le pays depuis le 1 er avril 2012. Jusqu à cette date, moins de 10% de la population était protégée par une assurance santé publique, privée ou mutuelle, et moins de 4% des indigènes (ca. 20.000 sur 455.000) étaient couverts par le Fonds Solidaire des Indigents (FSI), mis en place en 2005 afin de couvrir les exemptions du paiement des soins de santé. Population totale (millions) 9,1 (2011) Dépenses de Santé non Remboursées (% des dépenses de santé totales) Espérance de vie à la naissance, total (années) Mortalité infantile (pour 1 000 naissances) Mortalité maternelle (pour 100 000 naissances) Lits d hôpitaux (pour 1 000 personnes) Dépenses publiques en santé (% dépenses santé totales) Dépenses totales en santé (% PIB) 46,8% (2010) 55,6 (2010) 73,2 (2010) 350 (2010) 0,5 (2010) 49,5% (2010) 4,1% (2010) Source: Indicateurs du Développement dans le Monde Nom du programme Régime d Assurance Maladie Universelle (RAMU) Fonds Sanitaire des Indigents (FSI) Date de lancement 19 décembre 2011 2000, réformes en 2005 Etape Passage à l échelle nationale depuis le 1 er avril 2012 Passage à l échelle nationale depuis 2007 Population ciblée Toutes populations Indigents (5% de la population, ca. 455.000 habitants) et les enfants de 0 à 5 ans Lieu d opération National National Mécanismes pour atteindre les plus pauvres Exemptions Exemptions Identification des bénéficiaires au niveau des communes L identification et la validation sont menées par les Comités Locaux d Identification Villageois des Indigents (CLIVI), selon des critères adaptés à chaque situation. Méthodes d identification des plus pauvres Couverture du programmes Services couverts Paquet de soins Institutions gestionnaires / Rôles Sources de financement Aucunes données disponibles Consultations générales et spécialisées, soins infirmiers, médicaments, analyses, imagerie, explorations, hospitalisation avec chirurgie, CPN et CPoN, accouchements et césariennes, transport médical en urgence Ministère de la Santé / ANAM (Agence Nationale de l Assurance Maladie) FASNAS a, Etat, Collectivités Territoriales, Partenaires techniques et financiers (Banque Mondiale, BIT, Coopération Française, Coopération Suisse, OMS), Contributions des membres adhérents (5% des revenus du secteur formel ; 1,750 à 15,000 FCFA de contributions mensuelles des membres du secteur informel, selon leur secteur d activité ; aucune contribution des indigents). Moins de 20.000 bénéficiaires Gratuité des césariennes, santé préventive (vaccinations, déparasitage, supplémentation en vitamine A, distribution de moustiquaires imprégnées), traitement de maladies chroniques (VIH/SIDA, TB) couvrant examens, médicaments et alimentation Ministère de la Santé Etat (ligne budgétaire Secours et aides sociales, 1,25 milliards FCFA par an) a Fonds d Appui à la Solidarité National et à l Action Sociale

Points à retenir sur les programmes pour atteindre les plus pauvres Réussites Identification active des indigents grâce aux Comités Locaux d Identification Villageois des Indigents (CLIVI). Les CLIVI agissent avec le Projet d Appui à la Zone Sanitaire qui gère les dossiers d inscription à travers sa Plateforme Société Civile et Santé (PSCS), constituée de quatre facilitateurs dans quatre communes. Les facilitateurs accompagnent les bénéficiaires au centre sanitaire de leur zone où ils reçoivent leur carte d identification et peuvent ainsi bénéficier de services gratuits de santé grâce au Fonds Sanitaire des Indigents (FSI). Identification biométrique. Le FSI a lancé l identification biométrique des plus pauvres afin d avoir une base de données fiable et s assurer que ce sont les plus pauvres qui bénéficient des gratuités. Le RAMU reçoit un soutien fort du gouvernement. Le Président de la République est lui même impliqué dans le suivi et le développement du programme. Plusieurs partenaires ont également apporté leur soutien (BIT, OMS, Banque Mondiale, Coopération Suisse, Coopération Française). Un comité technique a été mis en place afin d assurer l infrastructure et l équipement des établissements sanitaires. Une campagne d information, d éducation et de communication a également été lancée afin de sensibiliser le public. Leçons à retenir / Défis et obstacles Le nombre de bénéficiaires du FSI est toujours faible (4% des indigents). Les difficultés liées à l identification active des indigents persistent. Les facilitateurs et agents sanitaires n opèrent pas systématiquement selon des critères d identification établis ou avec l appui des comités locaux. Les bénéficiaires ne sont pas uniquement les plus pauvres. Le terme indigent est souvent mal interprété et comprend les personnes capables de payer les frais minimum de soins. Les fonds publics sont alors dépensés sur des personnes non éligibles («fuites» dans le processus d enrôlement). Le RAMU manque encore de stratégie de pilotage. Il reste encore à résoudre certains points juridiques, le panier de soins et les mécanismes de paiement du RAMU. Il manque toujours de coordination intersectorielle ainsi qu un engagement des acteurs concernés (CLIVI, agents de soins, collectivités territoriales). Prochaines étapes L élaboration de critères plus uniformes afin d identifier les foyers éligibles est en cours. La Banque Mondiale s engage dans le Projet de Renforcement de la Performance du Système de Santé (PRPSS) afin de renforcer le programme santé au niveau communautaire et améliorer la méthodologie d enrôlement des foyers et d identification des segments de la population éligible. Les ressources humaines doivent être formées afin de mettre en place les plateformes adéquates pour ces cas. Le FSI reçoit l appui du Financement basé sur la Performance (FBP) qui permet d évaluer, par ailleurs, la qualité des soins accordés aux bénéficiaires. Les outils d évaluation développés dans le cadre du FBP seront transférés au RAMU. Desétudesactuariellesetdecoûtsdevaientêtreencoursderéalisationausecondsemestre2012en vue d affiner progressivement les options techniques et financières sur les dix prochaines années de mise en œuvre. Références Mathauer I, Ntamwishimiro Soumare A, Semegan B, Analyse du financement de la santé et réflexions sur le régime d assurance maladie universelle au Bénin, Rapport technique d une mission d appui de l OMS, décembre 2010. Plan National de Développement Sanitaire, 2009 2018, Ministère de la Santé. Tchibozo H, Atemenou A, Edon E, Ayi M, et al., Processus de mise en place d un Régime d Assurance Maladie Universelle (RAMU), Rapport d étape au 30 novembre 2011. Les Béninois disposent désormais d un Régime d Assurance Maladie Universelle (RAMU), Le RAMU a été officiellement lancé par le Chef d Etat, Dr Thomas Boni YAYI, Organisation Mondiale de la Santé, Bureau Pays du Bénin, Communiqué de Presse n 30 du 21/12/2011. World Health Organization, Providing for Health, Benin, P4H coordination desk mission report, February 2012, http://www.who.int/providingforhealth/countries/2012_02_17_cm BeninFebmissionreport.pdf (lien visité le 11 juillet 2012).

Ethiopie Améliorer la Couverture Sanitaire pour les Plus Pauvres : ETHIOPIE Contexte pays et Synthèse des programmes Mise en place en 1998, la stratégie de financement du système sanitaire en Ethiopie permet un cadrage pour les réformes destinées à mobiliser les ressources, en assurer leur utilisation équitable et efficiente, et améliorer la qualité et la prestation des services sanitaires. La stratégie soutient des réformes, y compris l imputation aux revenus afin d être reversée aux institutions sanitaires. Elle rend les dispenses systématiques afin de réduire les barrières financières pour les pauvres et standardiser les exemptions pour encourager l adhésion aux services sanitaires préventifs. Ces réformes ont été introduites dans un premier temps dans les trois plus grandes régions (Amhara, Oromia et la Région des nations, nationalités et peuples du Sud) du pays, et sont en cours d augmentation. La seconde phase des activités de réforme prévoit la mise en œuvre d un système d assurance maladie pour le secteur formel et de mutuelles pour le secteur informel. L assurance maladie devrait couvrir 12% de la population. Les mutuelles devront assurer les protection de 89% de la population. Nom du programme Dispenses Exemptions Mutuelles Etape Existant Existant Phase pilote, passage à l échelle Date de lancement 2007 2007 2011 Lieu d opération Toutes les régions sauf Afar et Somali Toutes les régions Mutuelles pilotées dans 13 woredas ou districts (dans le Amhara, Oromia, Région des nations, nationalités et peuples du Sud (SNNP) et Tigray), sélectionnés selon leur capacité en structure sanitaire. Mécanismes pour atteindre les plus pauvres Couverture du programme Population cible Dispenses des frais sanitaires Exemption Subvention générale et prise en charge à 100% des primes pour les indigents sélectionnés Les données sur le programme ne sont pas compilées à l échelle nationale. Les conseils régionaux collectent leurs propres taux de couverture. Les populations vivant sous le seuil de pauvreté (<1$/jour), 29% de la population. Il n existe pas de reporting du taux de couverture du programme à l échelle nationale. Des programmes séparés (VIH, TB, CPN, CPoN, accouchements, fistules, etc.) collectent leur propres données sur les taux de prise en charge. Toutes populations L objectif est de couvrir 50% de la population du secteur informel d ici 2015. Le programme pilote, mis en œuvre dans 13 districts, compte 125.142 chefs de ménages (99.565 contributifs et 25.577 noncontributifs) devenus bénéficiaires durant la 1 ère année de phase pilote, soit 42% des chefs de ménages en zones pilotes. Populations indigentes Services couverts Hospitalisation et consultations externes Hospitalisation et consultations externes Hospitalisation et consultations externes Méthodes d identification des plus pauvres Ciblage communautaire Toute personne est éligible, indépendamment du revenu Ciblage communautaire Institutions gestionnaires / Rôles Sources de financement Ministère de la Santé : définit la stratégie. Conseil régional : définit le cadre juridique pour mettre en œuvre la stratégie, met en place les ressources, surveille la mise en œuvre. Collectivités locales : obtiennent les institutions sanitaires qui mettront en œuvre le programme. Partenaires : assistance technique. Ministère de la Santé : définit la stratégie, assure les fonds. Conseil régional : définit le cadre juridique pour mettre en œuvre la stratégie, met en place les ressources, surveille la mise en œuvre. Collectivités locales : obtiennent les structures sanitaires, ressources humaines et fonds pour mettre en œuvre le programme. Partenaires : fournissent le matériel, les fonds et l assistance technique. Population totale (millions) 84,7 (2011) Dépenses de Santé non Remboursées (% des dépenses de santé totales) Espérance de vie à la naissance, total (années) Mortalité infantile (pour 1 000 naissances) Mortalité maternelle (pour 100 000 naissances) Lits d hôpitaux (pour 1 000 personnes) Dépenses publiques en santé (% dépenses santé totales) Dépenses totales en santé (% PIB) Source: Indicateurs du Développement dans le Monde Budget de l Etat Budget de l Etat,dons et legs Budget de l Etat 37,2% (2010) 58,7 (2010) 67,8 (2010) 350 (2010) 0.2 (2008) 53,5% (2010) 4,9% (2010) Ministère de la Santé : définit la stratégie, fournit les fonds. Conseil régional : définit le cadre juridique, met en place les ressources, surveille la mise en œuvre du programme. Collectivités locales : désigne les ressources, met en place le programmes. Partenaires : assistance technique.

Points à retenir sur les programmes pour atteindre les plus pauvres Réussites La dispense et l exemption sont deux composantes du programme plus large du paquet de la Réforme Financière Sanitaire (Health Care Financing Reform (HCF)). Les réformes HCF d Ethiopie comprennent : Première génération de réformes côté fournisseurs, tels que la retenue et l utilisation des recettes, fixation et révision des frais d utilisation, dispense et exemption, soutien de l autonomie des structures sanitaires grâce à la mise en place d un conseil d administration, externalisation des services non cliniques dans les hôpitaux publics et installation d ailes privées dans les hôpitaux publics. Seconde génération de réformes de l assurance maladie côté demande (Assurance Sociale Maladie, Mutuelles et Assurance Maladie Privée). Les Dispenses : Unmécanismed offredeservicesgratuitspourlespauvres.lesbénéficiaires éligibles sont sélectionnés et identifiés grâce à une participation communautaire. On remet aux bénéficiaires sélectionnés un certificat qui les dispense du coût de leur soins. Le ciblage communautaire participatif est un mécanisme efficace pour identifier les populations bénéficiaires en Ethiopie, où la majorité de l économie est informelle. Avant ces réformes, il n existait aucun moyen systématique d identifier les bénéficiaires. La performance varie d un district à l autre, mais généralement, le système de dispense à reçu un soutien politique. Chaque district doit mettre de côté un budget destiné au remboursement des fournisseurs pour les bénéficiaires de dispenses. Ceci est essentiel face aux priorités concurrentielles et aux restrictions budgétaires. Dans certaines zones où l aide alimentaire est associée aux gratuités des soins à travers le système de dispenses, les bénéficiaires offrent en échange desheuresdetravailaux activités de protection de l environnement, telles que le terrassement des terres, l agriculture, l afforestation, la construction de routes rurales, contribuant ainsi aux activités de développement local. Un exemple est la région d Amhara, la seconde plus peuplée d Ethiopie, où près de 19 millions d habitants vivent sur 157 347 km² et où 13,1% de sa population vivent dans des régions urbaines tandis que 86,9% vivent en régions rurales. La région est divisée en dix zones, trois administrations, 167 Districts, 3411 Kebeles (3113 ruraux et 318 urbains). Il existe 17 hôpitaux publics et 761 centres sanitaires. Tous les hôpitaux et 504 centres sanitaires mettent en place les réformes financières sanitaires y compris les dispenses et les exemptions. Les autres centres sanitaires devraient incorporer les réformes financières dans les deux prochaines années. Programme d exemption: Il nécessite que les structures sanitaires publiques affichent une liste des services exemptés dans leurs salles d attente. Les installations sanitaires sont responsables de la communication auprès des patients (affichages, campagnes publicitaires et autres formes de médias). Les services exemptés sont presque identiques dans toutes les régions et comprennent le planning familial, accouchements, soins pré et post natal, TB, Conseil et Dépistage Volontaire, PTME, lèpre, programmes et services ART. Les services exemptées couverts par les donneurs comprennent le Expanded Program on Immunization, le vaccin antitétanique, produits de planification familiale, les médicaments ARV et les kits de tests, et les antipaludiques. La part du gouvernement de budget couvre le salaire du personnel, les soins prénataux et les soins prénatals, l accouchement et le partage de coup pour l équipement médical des sources de l ONU. Le programmedes servicesexemptés bénéficieaussi de soutienpolitique, ainsi que de la communauté de donateurs et des ONG. Leçons à retenir / Défis et obstacles L accès aux populations bénéficiaires dans les régions isolées pour l identification et l enrôlement (fourniture des cartes d identification/certificats) est un défi majeur. Il est difficile de déterminer pour quelle durée de temps un foyer est indigent. La vérification/re vérification est un processus difficile. Aucun consensus n a été établi sur les méthodes de vérification. Certaines régions fournissent des cartes d identification tous les trois ans, d autres chaque année. La capacité des collectivités territoriales et des pouvoirs publics à remplir ces fonctions est faible. Dans un pays aussi grand et peuplé que l Ethiopie, il est difficile de vérifier, d évaluer et d obtenir l approbation et l appui des structures administratives et des villages pour les bénéficiaires proposés. Les frais de transport et de résidence sont des coûts supplémentaires pour les bénéficiaires de dispenses. Ceux ci sont envoyés dans des hôpitaux de référence situés dans les zones urbaines où le coût de vie est élevé. Un manque de médicaments essentiels, de fournitures, d équipement médical, de chirurgiens et de professionnels de la santé, dans les structures publiques, ralentit la qualité des services fournis aux pauvres. Le déficit budgétaire de l Etat limite l enrôlement de bénéficiaires supplémentaires et la disponibilité de ressources pour rembourser les structures sanitaires. Elle compromet également les programmes incitatifs destinés aux spécialistes et autres professionnels clés de la santé. Il en résulte que certains services ne sont pas fournis ou maintenus. Le system budgétaire du gouvernent n assure pas le suivi des ressources par type d intervention, mais utilise plutôt un système de lignes budgétaires (par exemple les salarie, les médicaments, le matériel, etc.) La plupart des lignes budgétaires reflètent des couts qui croisent plusieurs catégories, alors le budget alloué aux exemptions et à l assurance maladie n est pas connue. Les bénéficiaires de dispenses ne peuvent accéder aux services dans des structures privées dont les prix élevés ne sont alors pas remboursables par l Etat. Il manque une orientation claire sur la question du remboursement intégral ou partiel des services exemptés. Les bénéficiaires de dispenses suivent un processus de référencement afin d accéder aux soins des niveaux secondaires et tertiaires. Cependant, les structures sanitaires primaires (postes et centres sanitaires) situées dans des régions isolées ne sont pas encore équipées pour adopter ce système. Prochaines étapes Basé sur l expérience pilote, le réseau des Mutuelles sera développé afin de couvrir 50% de la population des secteurs informels d ici 2015. Les collectivités territoriales et régionales prendront en charge les primes pour la population indigente à travers les Mutuelles qui devraient couvrir 10% de la population totale (soit 8 millions d habitants). Le gouvernement fédéral dotera les Mutuelles d un fonds général, basé sur le nombre de foyers inscrits et correspondant à 25% des cotisations collectées. La mise en œuvre de l Assurance Sociale Maladie est attendue dans les prochains mois. Références Ethiopia Health Sector Financing Reform Midterm Project Evaluation, USAID, December 2011. Interview with: Genet Anteneh Delele, Regional Director, USAID/Health Sector Financing Reform Project, Amhara and Benishangul Gumuz Regional Office, Bahir Dar, Ethiopia

Ghana Améliorer la Couverture Sanitaire pour les Plus Pauvres : GHANA Contexte pays et Synthèse des programmes En 2003, le Ghana a adopté une loi et s est engagé dans un processus de développement et de mise en œuvre du National Health Insurance Scheme (NHIS) afin de palier les dépenses de santé non remboursées des usagers dans les établissements sanitaires. L autorité nationale d assurance sanitaire (National Health Insurance Authority, NHIA) a été désignée pour réglementer et surveiller le NHIS. On lui confie la responsabilité de gérer le National Health Insurance Fund qui verse les subventions aux programmes d assurance sanitaire mutualistes des districts. Ces District Mutual Health Insurance Schemes (DMHIS) gèrent le programme au niveau des districts. Les services sont fournis par le Ghana Health Service au sein du NHIS, des associations tels que le Christian Health Association of Ghana, et le secteur privé. Le NHIS est un programme volontaire qui fournit une couverture pour les employés du secteur formel et informel, ainsi que des exemptions aux femmes enceintes, les personnes âgées, les moins de 18 ans et les indigents que le NHIS définit par loi comme personnes sans revenus ou autres moyens et sans domicile. Population totale (millions) 24,9 (2011) Dépenses de Santé non Remboursées (% des dépenses de santé totales) Espérance de vie à la naissance, total (années) Mortalité infantile (pour 1 000 naissances) Mortalité maternelle (pour 100 000 naissances) Lits d hôpitaux (pour 1 000 personnes) Dépenses publiques en santé (% dépenses santé totales) Dépenses totales en santé (% PIB) 26,9% (2010) 63,8 (2010) 50 (2010) 350 (2010) 0,9 (2011) 59,5% (2010) 5,2% (2010) Source: Indicateurs du Développement dans le Monde Nom du Programme National Health Insurance Scheme (NHIS) Date de lancement 2004 Etape Passage à l échelle nationale Population ciblée Femmes enceintes, personnes âgées, les moins de 18 ans et les indigents (que le NHIS définit par loi comme personnes sans revenus ou autres moyens et sans domicile). Lieu d opération National Mécanismes pour atteindre Exemptions pour les indigents et les groupes vulnérables les plus pauvres Méthodes d identification des plus pauvres Les DMHI sont responsables de l identification et l enrôlement. Bien que des orientations pour identifier les plus pauvres existent, les mécanismes utilisés varient selon les DMHIS. Certains DMHIS se servent de représentants communautaires, d ONG et autres groupes non gouvernementaux afin d identifier et enrôler les plus pauvres. Avec le passage à l échelle récent du programme Livelihood Empowerment Against Poverty (LEAP), mis en place par Ministère de l Emploi et de Sécurité Sociale, le programme est utilisé de plus en plus pour inscrire les très pauvres au NHIS. Couverture du programmes 8.204.116 membres actifs (33,3%) (2011) 313.578 indigents (3,8%) (2011) Services couverts Paquet de soins Institutions gestionnaires / Rôles La couverture de 95% des problèmes sanitaires sont indiqués dans les établissements ghanéens. Elle comprend les soins externes, internes, la santé bucco dentaire, la maternité, les soins d urgence. Ministère de la Santé / Surveillance de la politique NHIA / Réglementation, surveillance, gestion des fonds DMHIS / Enrôlement des bénéficiaires, paiement des fournisseurs Sources de financement 72,7% 2,5% de taxe d assurance maladie ajoutée à la TVA 17,4% Contributions des employés du secteur formel au Social Security and National Trust (SSNIT) 5,3% Intérêts perçus sur le Fonds 4,5% Cotisations 0,1% Autres revenus 0,03% Dons et legs