Is Free Care Truly Free and Equitable? The Case of Liberia
CHALLENGES & LESSONS LEARNED
S. Tornorlah Varpilah
Tesfaye Dereje
Chris Atim
Major Health Indicators
Indication
Value
Year
Reference
Population
3,476,608
2009
National Census
Infant Mortality Rate
71
2007
LDHS
Under Five Mortality
110
2007
LDHS
Child Mortality
41
2007
LDHS
Life Expectancy
57.9
2009
Human Dev. Rep.
(UNDP)
Total Fertility Rate
5.2
2007
LDHS
Maternal Mortality Rate
994
2007
LDHS
Immunization Coverage (Full)
51%
2007/08
NHA
Total Health Expenditure
US 100,517,382
2010
Country Situation
Rep. (MOHSW)
GOL health Expenditure as % of
total government expenditure
7.73%
2007/08
NHA
Major Causes of Morbidity
Liberia’s Free Health Care Policy
• Basic Package of
Health Services
– Maternal and Newborn
health
– Child Health
– Adolescent, Sexual and
Reproductive Health
– Disease prevention,
control and
management
– Essential Emergency
Treatment
4
No User fee Policy Mandate
“In light of crushing levels of poverty, the
ministry has decided to suspend user
fees at the primary health care level”
“Suspension will remain in place until the
socio-economic situation improves and
financial management systems perform”
National Health Policy (P. 14)
“In accordance with MOHSW policy, user
fees for services included in the Basic
Package will be suspended at all public
facilities”
National Health Plan (P. 6)
5
Health Financing Landscape
• Total Health Spending ~ $105 Million
(~$29 per capita)
Private
Providers
53%
Donors
47%
Black
Baggers/ shops
19%
Households
35%
Government
Facilities
15%
Pharmacies
9%
Government
15%
Other Private
3%
Traditional
Healers
4%
6
Source: MOHSW, National Health Account 2007/08
Burden of HH Health Spending
Share of Household Spending on Health
(Among HHs that Reported OOP)
Income Quintile
Rural
7.0%
5
• Share of Health Spending
5.4%
4
out of total Household
9.8%
3
Spending
8.9%
2
16.4%
1
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
Income Quintile
Urban
– For Households that
reported out of pocket
spending: 9%
(catastrophic by the
7.5%
5
– Overall: 3.3%
4
10.0%
3
10.2%
2
10.1%
5% rule of thumb)
• The burden worsens for
the lower income
households
7
16.1%
1
0%
2%
4%
6%
8% 10% 12% 14%
Health Expenditure Share
16%
18%
Wang, 2009: Using
2008Community Survey data
Who’s Utilizing Government Health Services?
Government Health Service Utilization by Expenditure
Deciles
100%
90%
90%
Cumulative Share of Public
Health Service Utilization
100%
Cumulative Share of Public
Health Service Utilization
80%
70%
60%
50%
40%
30%
20%
80%
70%
60%
50%
40%
30%
20%
10%
10%
0%
0%
0%
20%
40%
60%
80%
100%
Hospital
Cumulative Share of Households
0%
20%
40%
Health Center
60%
80%
100%
Clinic
Cumulative Share of Households
8
Source: Ashagari & Wang, Benefit Incidence Analysis 2010
Distribution of Public Subsidies
Cummulative share of public Subsidies
100%
90%
Generally, pro-rich
~50% of the
Hosp. subsidy
80%
distribution of Public
70%
subsidies (CI =0.203)
60%
• slightly pro-poor
50%
at the clinic level;
Richest
30%
40%
• but Pro-rich
poorest
30%
30%
when it comes to
hospitals and
20%
15% of the Hosp.
subsidy
10%
health centers
0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Cummulative Share of Households
Hospital
Health Center
Clinic
All Levels
9
Source: Ashagari & Wang, Benefit Incidence Analysis 2010
Shortage of Pharmaceuticals
•
Ensuring drug availability is still challenging for both
– drugs flowing through National Drug Service and
– vertical programs
•
An average 50% of Health Facilities face drug stock-outs at a particular
point
– Proportion of facilities with no stock-outs varied from virtually none to nearly 70%,
ending the year around 50%.
(Assessment of 103 facilities in 7 counties revealed (in 2010)
•
From households perspective:
– Two-thirds complained about difficulties in accessing drugs
(Community Survey for Health Seeking Behaviour)
•
Concerns about leakage of drugs at facility level.
MOHSW/OPM, Health Financing Situational Analysis, 2011
10
Poor Physical Access
Average distance from Communities to Health Facilities
by Counties
Average distances
to the nearest
facility in most
counties well
beyond the
effective 5 K.M.
radius (one hour)
established by the
BPHS
11
Source: MOHSW, Country Situational Analysis Report (Draft), 2010
Unequal Distribution of Health Facilities
Number of Clinics and Size of Catchment
Population (2010)
Basing Liberia’s
BPHS Standard:
•40% cater to
population below
threshold
•10% are overcatering
12
Source: MOHSW, Country Situational Analysis Report (Draft), 2010
Poor Clinical Quality
13
Source: Quality Assurance Baseline Assessment Report (RBHS) Nov.2010
Challenges/ Imbalance
• Shortage of trained clinical health
workers
• Weak supply chain management
system
• Inadequate health facilities
• Weak M&E system
• Lack of standardized budgeting
mechanism
• Weak regulatory system for workers
Progress on Production Targets
No. of Health Workers Actual & Projected
1000
900
862
800
725
700
595
600
520
500
2006
454
416
2010
400
221
200
297
289
300
2011 Target
236
122
121
100
31 46
77
0
M.D.
P.A.
R.N.
C.M.
Pharmacist
Lessons Learnt (1)
• Know the cost implications
– Actuarial calculation taking into account
anticipated utilization increases
• Institute effective targeting
mechanisms
• Explore room to increase/ reallocate
resources to the identified priority area
16
Lessons Learnt (2)
– Strengthen supply chain management
system
– Strengthen regulatory system
– Strengthening Results Based Financing
– Improve budgeting mechanisms to link
resources required to health outcomes
17
Lessons Learnt (3)
• Establish an effective monitoring and
evaluation system
• Strengthen aid coordination mechanism
• Increase the number and quality of
health workers
18
Conclusion
• Free Care (user fee removal) is not the
final answer
• If unaccompanied by additional reform
measures to tackle expected supply side
constraints (esp. given it generates
demand that require catering) it:
– Over-stretches the resources available at the
public facilities with an impact on level and
quality of services provided
– Forcing the population to seek alternative care
which tend to be either more expensive
(private providers) or ineffective/dangerous
(black baggers).
19