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Making free healthcare pay in western Africa

I’ve just spent three days with 13 representatives of mainly western African countries to talk about how to finance healthcare in their countries. It was extraordinary.

This workshop was mainly organised by UNICEF, the World Bank and World Health Organization (WHO). It was designed to share experiences, knowledge, successes and failures. We were invited because of our expertise and our strong evidence-based advocacy and policy work on health financing.

The very fact that it was taken as a given that user fees should be removed everywhere was an incredible step forward compared to a few years ago. The debate was on how to remove them and what needed to happen for the quality of care not to drop as a result. Our guide to removing user fees, Freeing up Healthcare, was very useful in the discussions.

At the end of the three days, each country said what they planned to then do. Everyone recognised the need to know:

  • exactly how much money they’d require to finance user fee removal
  • to what extent poor people were benefitting from the free care
  • how much technical and financial assistance they’d need from donors to make it happen

The UK government and the World Bank are particularly key. The UK government because it has been a champion of equitable financing for many years, and the World Bank because it is one of the major health donors and somehow needs to atone for being behind the introduction of user fees in Africa in the first place.

Save the Children will continue to work with the UK government to ensure that people have access to healthcare even if they are poor, and with countries to support them practically in the implementation of free care. We have, for example, worked very closely with Sierra Leone in ending health fees there, and are working with Liberia, Rwanda and many others.

Possible replacements for user fees were also discussed. It was interesting to hear the enthusiasm towards Performance Based Financing (PBF) and Community Based Health Insurance (CBHI). PBF is often talked about as a way of supporting free care yet it has numerous limitations (particularly the need for rigorous evaluation, which is costly and difficult).

CBHI is an improvement on user fees since people generally don’t have to pay when they’re sick, but it has not brought about universal coverage, still excludes the poor who can’t pay the premium and doesn’t raise enough money to be financially sustainable.

We must make sure that whatever replaces user fees does not discriminate against those less able to pay. The debate about the best approach will continue, particularly at the launch of the WHO’s World Health report, Health Financing to Achieve Universal Coverage, on 22 November in Berlin. We will be there to share with you whether there’s cause for celebration or not!

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