Some operational lessons In most countries, the initiative came from the highest national political level, sometimes as a result of external pressures. This level of political will translated into wide mobilisation. When African leaders clearly state their priorities, national and international partners tend to follow them. For the most part, the initiatives suffered from a lack of preliminary consultation and inadequate preparation (situation analysis, costing, logistics planning). Even though initiatives that have been studies and documented do tend to respond to some previously neglected needs, they also have the potential of disrupting other health system functions (for example, national drugs supply). Decision-makers did not always consider the interactions between those functions when developing user fee abolition policies. The definition of a package of services to advance MDGs requires analysing the major causes of maternal and child mortality in a given country, as well as analysing the cost of various mechanisms and combinations of mechanisms to address those causes. It is important to avoid a situation whereby the user fees abolition would happen at the expense of more efficient activities (for example, a preventive care package). This merely underscores the importance of good coordination between and technicians before engaging into resource-consuming initiatives. When all the costs of accessing services (transportation etc.) are not taken into account, there is a risk that the poor benefit less than the rich from the exemption policy. This risk can be avoided by considering the system as a whole, including other financial barriers (apart from user fees), as well as other barriers to access to health care (geographic, cultural, reception and quality of care) and their determinants (human resources, equipment, supply). Experience shows that, in order to ensure proper financing, additional resources should be raised and earmarked for the initiative – yet most countries have not yet kept their commitment to allocate 15% of their national budget to the health sector. To mobilise these resources, some countries strive to get support from other ministries (Finance, Transport, Social Welfare, etc.), or other projects aiming to reach the MDGs. Some countries began to create new taxes, but they have not been uniformly “progressive”. The issue of governance is central. Recommendations for Policy Development Before making a political decision regarding the abolition of user fees, conduct a wide consultation with all concerned line ministries (Health, Economy and Finance, Social Welfare, Transportation etc.), NGOs, technical and financial partners (TFPs), civil society and the community. makers effective
We want to acknowledge the presence of African researchers and practitioners, whose roles are of utmost importance, not only to ensure the success of this workshop, but also to guarantee the follow-up of the activities that will be defined and agreed upon during the workshop. Gianfranco Rotigliano UNICEF Regional Director for West and Central Africa Principles of a Community of Practice A Community of Practice (CoP) is a group of people who decide to deepen their knowledge and expertise in an area by interacting on an on-going basis (Wenger and al. 2001). The concept was originally developed to address the fact that learning also takes place through social relationships rather than only through formal teaching or books: this “tacit knowledge” is shared between peers and practitioners of a given field. The application of this concept to public health is quite recent. A CoP brings together experts from various departments, organisations or countries. It focuses on individuals and practical knowledge (know-how). It is governed by its own members, who identify key knowledge areas, priorities and activities. Towards a CoP on Financial Access During the HHA partners meeting in June 2009 in Bamako, a number of CoPs was created and organised according to health system’s pillars (cf. annex VIII). As a priority issue to the African country representatives, a Health Insurance CoP was initiated under the Health Financing pillar. In July 2010, when HHA partners reconvened in Kigali, the decision was made to broaden this CoP in order to address other mechanisms to improve financial access. Consequently, the Health Insurance CoP was renamed “Financial Access (FA) to Health Care CoP”; it will comprise several groups, such as health insurance, user fee exemption etc. Experience of the Performance-Based Financing CoP As an illustration of how a CoP works, the PBF CoP’s experience was presented. This CoP, whose members currently number more than 190, develops various activities for national experts. It has helped a country like Burundi to advance its policy work. The recommendations from this experience are the following: Target individuals, not organisations.
Annex I: HHA Workshop Agenda: MORNING Time Tuesday – 2 November 2010 Chair: UNICEF Time Wednesday – 3 November 2010 Chair: WAHO Time Thursday –4 November 2010 Chair: UNFPA 8.30-9.00 Registration 8.30-8.45 15 minutes Welcome Review of the agenda 8.45-9.00 15 minutes Welcome Review of the agenda 9.00-10.10 Opening Ceremony Welcome word from partners Mr Gianfranco Rotigliano Introduction and workshop objectives - Kossi Atsou Speech from the Representative of the Government of Senegal 8h45-10.00 (20 min presentation + 10 min clarification per country, + 15 min discussion) Experience of East African countries: Burundi Ethiopia 9.00 – 10.30 90 minutes Report of Working Groups 2 Presentation and discussion in plenary session Synthesis of recommendations - Allison Kelley 10.00-10.30 Coffee Break 10.30-11.00 Presentation (15 min) Q&A (15 min) Financial access to health services: Evolution of perspectives, UNICEF Study on the Abolition of User Fees - ITM Antwerp (B. Meessen) 10.00-10.15 Report of parallel sessions and Synthesis of salient points from Country presentations- Kodjo Evlo 10.30 – 11.00 Coffee Break 11.00-12.30 Building the future: The Community of Practice “Financial Access to Health Care” What is a community of practice? (15’) CoP FAHC: past activities, opportunities, governance and early propositions (15’) Debate with participants (60’) Chris Atim and Bruno Meessen 10.15–10.30 Coffee Break 11.00-13.00 20 minutes presentation per country + 10 min for clarification + 30 minutes for general discussion Experience of West African Countries: Sierra Leone and Burkina Faso Ghana 10.30-11.00 Introduction to working groups: Seni Kuanda Explanation of themes, Organisation of groups and work, Expected outputs 11.00-12.30 Working Groups 1 Parallel sessions on following themes: A/ Interaction between policy work and technical work, respective obligations and coordination mechanisms B/ Targeting and coverage of the poorest (complementary measures) C/ Definition of target populations and package of services D/ Financing policies through the national budget and financial partners 1.00-2.00 pm Lunch Break 12.30-1.30 Lunch Break 12.30-1.30 Lunch Break