User Fees and AIDS Response False Economies and Inequities Iris Semini seminiiunaidsorg July 2018 1 AIDS related deaths the lowest in the century Little change in new HIV infections outside of subSaharan Africa ID: 812860
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Slide1
Addressing Barriers – Accelerating Action towards Fast Track Targets
User Fees and AIDS Response – False Economies and Inequities
Iris Semini
(seminii@unaids.org) July 2018
1
Slide2Slide3AIDS related deaths the lowest in the century, Little change in new HIV infections outside of sub-Saharan Africa
Slide4Progress varies by region
Slide5Children in western and central Africa being left behind
Cascade of services for preventing vertical transmission, number of new infections and transmission rate, 2017
Western and central AfricaEastern and southern Africa
Slide6Structural Barriers to achieving Fast Track Targets
6
Slide7Barriers to HIV and Health Services – Perspectives of People Living with HIV
The third most mentioned barrier:
User fees: official payments at the point of care Costs for medication, tests, visits, and medical fees are the third most mentioned barrier to HIV and health servicesSource: Asghari, S., Hurd, J., Marshall, Z., Maybank, A.,
Hesselbarth, L., Hurley, O., . . . Liddy, C. (2018). Challenges with access to healthcare from the perspective of patients living with HIV: A scoping review & framework synthesis. AIDS Care, 30(8), 1-10.7
Slide8Fees as barriers to testing, PMTCT, pediatric care
Source: Landefeld and al.
Prevention of Mother-to-Child Transmission of HIV in Yaounde: Barrier to Care. AIDS Care 2018
8
Slide9Several Charges at the Facility Level-Barriers and cause of inequities
Illustrative example: Payments by the client in DRC
PrestationsAmount (US$)
PlaceHealth Facility
Source
HIV Testing 3
Mbuji
mayi
/ Kasaï Oriental (4 zones de santé)
FOSA
Observatoire, 2017
Consultation
1.15-1.25
Goma et
Karisimbi
FOSA
Observatoire, 2014
2-5
Lubumbashi
Hospital
MSF
CD4
15-20
16
RDC
Kinshasa
Hospital
FOSA
MSF
Observatoire, 2017
Hospitalisation
200
Lubumbashi
Hospital
MSF
160 - 280
Kinshasa
Hospital
MSF
PMTCT7Nord Kivu FOSAObservatoire, 2017STI5,5Nord KivuFOSAObservatoire, 20171Mbuji mayi / Kasaï OrientalFOSAObservatoire, 2017Family Planning5Nord KivuFOSAObservatoire, 2017TB0.50Mbuji mayi / Kasaï OrientalFOSAObservatoire 2014
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Guinee, Zimbabwe, Cameroon, DRC, Nigeria, and other countries
the cost of OI, laboratory tests, CD4, viral load
>
20% to 50% of household total income reaching
Lubumbashi study (DRC): average over 200 USD, exceeding patients’ monthly income in 63% of cases (MSF, 2017).
Slide10Effect
on Treatment Cascade
Slide1111
Countries charging user fees in public clinics and hospitals in SSA countries
Source: World Bank Universal Health Coverage Study Series No. 26
Global Consensus – to move away
from user fees and progress
towards UHC – Slow pace of implementation
Slide12High out-of-pocket spending in all regions
Slide13Country Leadership – Solutions - Capacities
Country leadership commitment, country-based solutions determined by health financing models and structures Sustainable solutions: Health financing as part of UHC where fee removal occurs must be accompanied by increased national budgets for health care to protect the quality of health care In the meantime, countries have selected specific opportunities to move away from user feesFor Selected ServicesFor Geographic Areas
For populations Impact of Policy Decision to move away from user fees is determined by effective implementation and improving the supply-quality deliverzEarly Planning with all partners, communities, health staff, and donorsDonor financing to offset potential immediate financial loss in facilities (and strengthen the health services)13
Slide14Source: Yates R. Universal health care and the removal of user fees. The Lancet 2009; 373: 2078-81
14
Source: Yates R. Universal health care and the removal of user fees. The Lancet 2009; 373: 2078-81
Abolishing
User
Fees
in
Kisoro
District - Uganda
Slide15Burkina Faso: under 5 years and pilot exemption
Source: Zombré et al, 2017; Ridde et al, 2013Evolution of the mean rate of health service utilization among children under five in comparison and intervention districts, 2004 - 2014.
15
Slide16Jamaica Improvement of Access for Children under 18
Those poorer benefited the most from the increased on utilization
16Li Z, Li M, & al. User–fee–
removal improves equity of children’s
health care utilization and reduces
families’ financial
burden
:
evidence
from
Jamaica
.
Journal of Global
Health
. 2017
The difference in health care utilization between children in poverty and children not in poverty, among under-18 children fell ill in the past 4 weeks.
Slide17Impact of Removing the User Fees
Impact of removing user fees: results from longitudinal data
OutcomeImpact just after the intervention
Impact 12 months afterMoses 1992 Kenya (1988-1993)
New monthly outpatient visits by women
43.6%
88.6%
New monthly outpatient visits by men
49.2%
68%
Nabyonga
2005
Uganda (2000-2002)
Average monthly No. of 1
st
ANC visits (intervention sites)
-5.8%
4.7%
Collins 1996
Kenya (1990)
Monthly No. of outpatient visits in district hospitals
48.4%
18.1%
Monthly No. of outpatient visits in provincial hospitals
29.6%
18.1%
Burnham 2004
Uganda 2001-2002
Monthly average No. of outpatient visits of all patients
38.9%
41.3%
Utilization of preventive services (immunisation)
18%
41.6%
Wilkinson 2001
South Africa (1992-1998)
No. of monthly outpatient visits by adults
50.8%
92.6%Preventive services: No. of ANC visits65.2%36.2%Source: (Lagarde 2011) 17
Slide18Malawi: low income and positive results
The sustained low level of OOP expenditure and low incidence of catastrophic OOP spending in Malawi could be attributed to the policy of free health care. (Source: WB Case Study, 2017).
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Slide19The impact of user fees on health services utilization and infectious disease diagnoses in Neno District, Malawi
Introducing user fees: The presence of user fees changed total attendances by −68 % [95 % confidence interval: −89 %, −12 %], new malaria diagnoses in the over 5 s by −56 % [−83 %, +14 %]Confirmed HIV cases in people aged 15–49 by −48 % [−64 %, −25 %], potential impact on HIV testing in outpatient services Removal of user fees: increase in total outpatient attendances of 352 % [213 %, 554 %], new malaria diagnoses in the under 5 s and over 5 of 230 % [106 %, 430 %] and 247 % [171 %, 343 %]
New introduction of user fees led to large, significant declines in outpatient attendances, which also translated into an indirect effect of reductions in new diagnoses of malaria and HIV19Watson et al. BMC Health Services Research (2016) 16:595
Slide20Discouraging user fees in Malawi
Malawi has never charged user fees in public health facilities, and has a child mortality rate of 64 deaths per 1,000 – in contrast to 109 in Nigeria, which is seven times wealthier.
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Slide2121
Sustained Political Commitment throughout implementation: Sierra Leone’s free health care initiative
Slide22The free healthcare initiative in Sierra Leone: Evaluating a health system reform, 2010‐2015
Source: The free healthcare initiative in Sierra Leone: Evaluating a health system reform, 2010‐2015, First published: 12 January 2018, DOI: (10.1002/hpm.2484)
Consultations for children under five increased by 60%
Malaria consultations for the same age group increased tenfold
Continue donor support to:
Sustain the system
Strengthen human resources
Sustain the increase on service utilization
Slide23Lead Implementation to Address Challenges
Requires significant focus on planning and implementation
Secure resources to offset potential loss of facility-based financial resources from the user feesWhen user fees were abolished in Uganda, health facilities lost revenues and had difficulty meeting recurrent expenses until compensatory funds were released (Kajula et al. 2004; Yates et al. 2006). 23
Poor Adherence to the policy - Kenya Lead Implementation
Slide2424
Proposed options for discussions and debate
Source: V. Ridde
Slide25PEPFAR Leadership has placed it at the
centre of dialogue with Country Partners The path to longer and healthier lives for all Africansby 2030: the
Lancet Commission on the future of health in sub-Saharan Africa – December 2017A key priority is the reduction of out-of-pocket payments: ..In more than a third of sub-Saharan countries, such payments make up more than 40% of total health expenditure. Further progress is needed to remove user fees
and ensure poorer people benefit the most from health insurance schemes.Miles to Go: UNAIDS, 2018
Reaching global HIV testing and treatment targets will depend a great deal upon efforts to address the huge coverage gaps in western and central Africa…progress towards the catch-up plan targets will require the expansion of community-based HIV testing services, steady removal of user fees for HIV and health services,…..
25Build on the political momentum to advance country solutions
Slide26User Fees and AIDS response – False Economy and Inequities
Rapid scale up is essential for the HIV responsePotential revenues generated through user fees are largely offset by the high cost of delayed access the HIV and AIDS-related services, adherence
Failure to achieve HIV Fast Track targets will add US$ 4.7 billion additional budget requirements in sub-Saharan Africa from 2017 to 2030User charges for CD4, blood tests, OI reduce adherence, increasing costs of treatment Those poor and marginalized become poorer and don’t access services
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Slide27In country-approach to identify solutions to move away from user fees
In-country consultation with government, people living with HIV, partners, and donors to build a power base around this topic, devise potential solutions, oversight of implementation, measure results Generate Data on user fees and impact in each tier of implementation cascade (costs and barriers for patient perspective and health provider) to make the case for early interventionGranular info to determine focus: high burden areas / services where user fees affect access and revenues. For example, HIV testing brings the least revenues and can be a manageable starting point Identify donor financing to offset potential immediate financial loss in facilities (and strengthen the health services) by removing the user fees for the patients
Solutions need to address the supply side and the demand side (e.g lack of tests or drug supplies will reduce effect of removal of user fees)27
Slide28In country-approach to identify solutions to move away from user fees
RBF (not the only possibility): an important entry point: Strengthens the supply side through up-front agreement between funders and service-providers where payment depends on the delivery of outcomes, with independent verificationRBF has in some countries influenced substantial reduction in unofficial provider fees, payments for laboratory tests and transportation fees
Example of collaboration : Map high-burden areas vs RBF coverage areas to identify priority area for joint actionRBF will strengthen the services, supplies, and finance the user chargesThe implementing partners, donors and communities focus efforts on increasing demand and access to the RBF covered areas addressing the other access barriers. Document where is working and share country experiences Continue to promote progressive health financing strategies and “to resist the temptation to rely on user fees.” (WHO, 2008) to consolidate progress towards UHC
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Slide29Acknowledgments
Robert Yates, Chatham House Valery Ridde, IRD Mit Philips, MSFRene Bonnel, Independent Senior Economist