Second Conference of the African Health Economics and Policy Association: towards universal healthcare coverage in Africa

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Abstract
This report discusses the key messages coming out of the papers presented at the second African Health Economics and Policy Association conference, with a particular focus on innovative and recent research results of interest to a wider audience. It also covers the scientific structure and organization of the conference, including the various sessions and key note speeches. The 3-day conference discussed the definition and scope as well as the key issues concerned, the challenges involved, and the role of leadership and country ownership in achieving universal health coverage in low-income countries. A special effort was also made to link the research outputs of the conference to policy-making in the region, through the participation of high-level decision-makers from countries as well as the production of policy briefs targeting policy-makers and based on the conference outputs and relevant research. Sub-themes of the conference included user fee removal and exemptions, covering those outside the formal sector, improved domestic funding of healthcare, purchasing of services and policy processes. The conference was attended by approximately 230 participants drawn from over 30 African countries as well as abroad, mostly from academia, research institutions, Ministries of Health and other relevant Government agencies, as well as donor and technical partners.
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Meeting Report
The theme of the Second African Health
Economics and Policy Association (AfHE A)
Conference was ‘Towards universal healthcare
coverage in Africa’. This theme was chosen
by the AfHEA in recognition of the fact that
this issue has risen to the top of the agenda of
inter national public health, especially in many
developing countries. In recent years, many of
these countries have been moving towards the
goal of providing healthcare coverage for the
entire population, and in particular ensuring
cover for poor and vulnerable groups that are
usually unable to achieve such coverage with
their own resources.
The international movement towards univer-
sal coverage includes rights-based and human
capital perspectives that are increasingly present
in international debates and policy discussions.
The fact that ensuring good health for all is
good policy for viable and long-term social and
economic development was recognized by the
WHO in the 2005 World Health Report, which
called for countries to move towards replacing
out-of-pocket (OOP) expenditures with prepay-
ment mechanisms (tax funding and insurance
payments) to enable each and every one to have
access to health services without financial bar-
riers at the point of service. This international
trend culminated in the publication late in 2010
of the World Health Report on ‘Health systems
financing: the path to universal coverage’ [1].
The AfHEA conference theme therefore finds
its relevance and topicality within this global
context. Africa, after all, is the continent that
has the highest percentages of OOP expenditure
both in terms of total health spending and in
terms of the proportion of private health expen-
ditures. WHO statistics show that the share of
private spending in total health expenditures
in the Africa region stood at 54.7% in 2007, of
which 60.1% was OOP expenditures (WHO,
World Health Statistics 2010). These averages,
however, mask some extreme country cases, such
as the Central African Republic, Sudan, Togo,
Cote d’Ivoire, Cameroon and Nigeria, where the
percentage of OOP spending out of total health-
care expenditure is well above 60%, and Guinea
where it is nearly 90% [2]. Clearly, this is an acute
and urgent problem in some of the countries of
this region, as OOP spending has been demon-
strated to have an impoverishing effect on poor
and vulnerable sections of the population [3–6].
Chris Atim
African Health Economics and Policy
Association, World Bank, Dakar,
Senegal
Tel.: ASK AUTHOR
Fax: ASK AUTHOR
chrisatim1@gmail.com
Second African Health Economics and Policy
Association Conference
Saly, Senegal, 15–17 March 2011
This report discusses the key messages coming out of the papers presented at the second African
Health Economics and Policy Association conference, with a particular focus on innovative and
recent research results of interest to a wider audience. It also covers the scientific structure and
organization of the conference, including the various sessions and key note speeches.
Keywor ds:
health economics in Africa • health nancing • health nancing policy in Africa • universal coverage
Second Conference of the
African Health Economics and
Policy Association: towards
universal healthcare coverage
in Africa
Expert Rev. Pharmacoeconomics Outcomes Res. 11(3), xx x–xxx (2011)
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Expert Rev. Phar macoeconomics Outcom es Res. 11(3), (2011)
2
Meeting Report
Structure & organization of the conference
The AfHEA 2011 conference brought together approximately
230 experts, academics, researchers, practitioners and policy
makers from over 30 African countries, as well as Europe and
North America. It was partly funded by participant fee payments
and partly also by partners including the Bill and Melinda Gates
Foundation, the International Development Research Centre
(Canada), the Rockefeller Foundation, Providing for Health,
United Nations Population Fund, WHO and the World Bank.
The conference consisted of 3 days of scientific discussions,
comprising approximately 75 high-quality presentations in
20 parallel or concurrent sessions and six plenary keynote pres-
entations. The presentations were selected by Af HEA’s scientific
committee from over 300 abstracts submitted earlier in 2010.
Approximately another 60 abstracts were accepted for poster
presentations.
The sub-themes of the concurrent sessions included:
• ‘User fees – removal and exemptions’;
• ‘Covering those outside the formal employment sector’;
• ‘Improved domestic funding of healthcare’;
• ‘Purchasing of services’;
• ‘Policy process and actors’.
There were also sessions on economic evaluation, service access
and other financing issues.
Plenary keynote presentations included a presentation of the
WHO report on the path towards UHC by Dr Jean Perrot on
behalf of the report author, Dr David Evans (both of WHO),
and a presentation on the nal day of the key messages of the
conference by Professor Diane McIntyre of the University of Cape
Town, South Africa, supported by two discussants. In addition,
there were two lively panel debates, one dealing with the chal-
lenges of achieving universal coverage in low-income countries,
and the second on the role of leadership and country ownership
in achieving universal coverage.
There was also an emphasis at the conference on the link
between research and policy, applied to the area of universal cov-
erage. This was shown by the participation of high-level policy
makers (representatives of key regional policy making bodies such
as the African Union and two sub-regional health organizations,
several members of the Nigerian legislative branch, a deputy
Minister of Health of Liberia, and several senior Ministry of
Health technocrats). This was further expressed by the develop-
ment of policy briefs immediately after the conference, and based
on its key messages.
From the rich menu of conference presentations, we discuss in
this paper those that had the most relevance or that presented the
most innovative findings in the areas that drove the conference
agenda, namely regarding the definition and scope of the main
theme, the challenges of achieving universal coverage in low-
income settings, the role of leadership and country ownership
and making a link between research and policy.
Key findings
Definition & scope of main conference theme
The presentation by Jean Perrot on behalf of the author of WHO
Report on the first day of the meeting helped to frame the context
for the conference theme and subsequent discussions [7]. He defined
universal health coverage (UHC) as involving two key compo-
nents: first, providing protection from financial risk or the financial
consequences of accessing healthcare; and second, availability or
effective access to quality healthcare in times of need. This defini-
tion goes beyond providing protection against user fees at health
facilities and encompasses other patient costs, as well as other bar-
riers that hinder effective utilization of health services by all who
need to do so. He emphasized that providing financial protection
for health services of bad quality, as was prevalent in some countries
in Africa in the 1970s and 1980s, or providing good-quality care to
which large segments of the population have limited or no access,
would not satisfy the criteria for universal coverage in this context.
In terms of the first component (i.e., protection from financial
risk), Perrot argued that the strategy to achieve this in practice
requires that user fee payments at the point of service must be
abolished, by replacing them with other mechanisms, such as
prepayments (tax funding or insurance payments), direct supply-
side subsidies (usually for certain priority groups and/or services)
or demand-side subsidies (conditional cash transfers, vouchers,
etc). However, the speaker also recognized that there is a valid
debate about the role of user copayments or deductibles even in
the context of UHC. Similarly, in the case of developing coun-
tries, there is also a valid discussion to be had about the role of
external or donor funding as one of the sources for financing the
protection against health risks.
The speaker also noted that some legitimate questions do
arise regarding some of the approaches adopted in countries
towards the goal of coverage for all or for vulnerable groups
against nancial risks of illness: for example, is it really pos-
sible to achieve UHC by relying only on voluntary health insur-
ance schemes? Similarly, is it possible to attain the objective
through a large number of independent insurance schemes (a
fragmented system)?
In terms of strategies for improving the quality of health services
in African countries, the speaker suggested the following:
• Raising the share of financing going to health, such as via
movement towards fulfilling the Abuja Declaration commit-
ment by African countries to devote 15% of Government budg-
ets to health, and for donors similarly to move towards their
commitments to devote 0.7% of their fross domestic products
to external aid;
• Innovative nancing mechanisms including, at the country
level, new taxes on mobile phone usage, sin taxes etc; and at
the global level, airline taxes and the global health initiatives,
for example;
• Other efforts to improve healthcare quality through implication
of other actors including the private sector, communities and
civil society.
Atim
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Finally, the author argued that the two components of UHC
(i.e., the protection from financial risks and availability to all of
quality health services) are inter-related. This is because when
quality health services are available, it is easier then to develop
mechanisms for financial risk protection, while the development
of mechanisms for financial risk protection make more resources
available to improve healthcare quality.
Challenges of achieving UHC in low-income countries
Owing to the Sub-Saharan African (SSA) country context and
focus of the conference, it is not surprising that many presenta-
tions dealt with the challenges of achieving universal coverage in
low-income settings, in addition to a plenary session dedicated
to that sub-theme.
The challenges discussed by many presentations have to do
mainly with the twin issues identified in the definition of UHC by
the WHO Report cited above: ensuring both adequate financing
and availability of quality health services for universal coverage.
Related implementation challenges also discussed include how
to cover the large sections of the population that live and work
outside the formal economy in SSA countries.
The presentations showed varied country approaches to achiev-
ing the UHC goal. Many countries in SSA have opted for the
outright removal of user fees at the facility level either for all the
population or, more frequently, for targeted vulnerable groups
or for priority health services (usually maternal and child care).
Other countries have opted for national health insurance schemes
based on a combination of tax funding and insurance contribu-
tions. It should be noted that no country among the cases pre-
sented at the conference comes close yet to achieving UHC in
the sense of the two dimensions specified in the WHO Report.
Presentations on user fee removals showed that such initiatives
were often not backed up by making adequate resources available
to deal with the predictable utilization increases and other pres-
sures on health systems that the fee removals engender. This was
illustrated by the presentation of Uzochukwu et al. (University
of Nigeria) [8]. The authors found that following user fee removal
in Enugu, South-East Nigeria, service utilization indeed rose, but
that this also led to increased staff work load, shortages of drugs
and increased waiting times, while (perhaps as a result of these
factors) patients in fact continued to pay for the ‘free’ services.
These findings are broadly similar to those for North Sudan [9].
There were some notable examples of innovative approaches
that could provide lessons for progress towards the UHC goal. In
terms of population coverage, Rwanda appears to have made the
most progress through social health insurance, reaching approxi-
mately 85% of the population in 2008 [10]. Ghana has similarly
made remarkable progress after only 5 years of implementation of
a national health insurance scheme, attaining, according to one
presentation, approximately 66% of the population by 2010 [11],
although it is important to point out that some other research
sources put the real coverage at between 30 and 50% of the popu-
lation [12]. The most significant lessons from this experience are
arguably the innovative financing mechanism (largely based on an
earmarked 2.5% value-added tax that is levied on consumption
excluding items commonly consumed by the poor) and the exten-
sive exemptions for the most vulnerable groups in the country:
indigents, children up to the age of 18 years, pregnant women
and the elderly and pensioners. These exempted categories make
up more than 70% of scheme membership. However, there is
evidence that the scheme membership to date is more pro-rich
than pro-poor, and that premiums paid by the informal sector
are regressive, issues that the Ghanaian authorities are trying to
address [13]. Another country that has shown innovation in ear-
marked financing for social health insurance is Gabon, where
mobile phone companies pay 10% of their revenues, and transfer
of funds abroad are taxed at 1.5% as well [14].
In terms of tackling the healthcare quality dimension of UHC,
it appears that it is the insurance-based systems that are show-
ing the most potential to achieve this also. This is because such
systems not only bring more resources (e.g., the Ghana scheme
pays significant subsidies directly to the Ghana Health Service for
investing in health services), but some of them also tend to use
their negotiating power to accredit providers and otherwise try
to alter provider attitudes through, for instance, imposing new
payment mechanisms. The Rwandan scheme is tightly integrated
into a performance payment system that has been reported to
improve quality of care, although it is arguable that this cannot
be attributed to the insurance schemes per se.
Role of leadership & country ownership in
achieving universal coverage
Several presentations on the UHC reform process in countries,
as well as a plenar y panel discussion on the subject, clearly
showed the critical role of leadership in moving towards UHC
[15]. Despite this, in practice it appears that there has tended
to be a tension between political leadership and the technical
design group or the technocrats. Frequently, especially with
user fee removal policies, politicians tend to make the policy
pronouncement for electoral reasons without any prior input
from the technical people, including a lack of any ana lysis of
the financial and other resource implications. This is clearly
illustrated by the presentation of the Burundi experience with
user fee removal for maternal care and children under the age of
5 years [16]. The result is that implementation is often beset by
the challenges previously noted, i.e., increased utilization with-
out adequate funds to cope with this, drug shortages, increased
waiting times and under-the-table payments that undermine the
original purpose of the policy.
The panel discussion on this sub-theme highlighted the afore-
mentioned tensions, but also called for a more collaborative rela-
tionship between the political leadership and the technocrats in
the design of UHC policies, as well as for careful planning and
phasing-in of implementation, including a need to allocate more
funding to cope with the resulting utilization increases.
Country ownership was addressed in the panel discussion as
requiring that countries take ownership of UHC policies includ-
ing coordinating the interventions of various actors and setting
the agenda and objectives of policy in line with the country
policies.
Second Conference of the African Health Economics & Policy Association
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Meeting Report
Making the link between research & policy
In addition to the participation in the conference of high-level
policy-makers, a technical working group led by the scientific
committee of Af HEA met on the day after the conference to
discuss the production of policy briefs that would be used in
advocacy and technical assistance work with regional and coun-
try policy-makers by Af HEA’s leadership. These briefs are to be
based on the key messages of the conference and other innovative
research and thinking in the area of UHC. The technical working
has agreed the broad outlines of the briefs, and these are expected
to be ready in time for meetings of regional health bodies starting
in May 2011.
Conclusion & next steps
The AfHEA 2011 conference achieved all of its objectives, in terms
of number and quality of presentations, number of participants,
forging links with policy makers and level of participant satisfac-
tion as shown by the ana lysis of the evaluation forms. This is only
the second scientific conference organized by Af HEA since it was
created in 2009, but this is already a strong foundation to build
upon in offering African health economists and policy experts
a forum to promote quality research and the use of the tools of
economic and policy ana lysis in health sector decision-making.
The African Health Economics and Policy Association intends
to use the policy briefs under preparation in further interactions
and technical assistance work with regional and country policy-
makers in Africa. Information on the next conference venue and
dates will be published on the Af HEA website before the end of
2011 [101]. All the conference presentations are also available on
that website.
Financial & competing interests disclosure
The author has no relevant affiliations or financial involvement with any
organization or entity with a financial interest in or financial conflict with
the subject matter or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or options, expert
testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
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  • Ghana's National Health Insurance Scheme (NHIS): an analysis of the NHIS' contributions to health care coverage, financial protection and health financing. IDA16 Success Stories Series
    • C Atim
    Atim C. Ghana's National Health Insurance Scheme (NHIS): an analysis of the NHIS' contributions to health care coverage, financial protection and health financing. IDA16 Success Stories Series. World Bank, Washington, DC, USA (2010).
  • Removal of user fees for maternal and child health services in Enugu, South East Nigeria: experiences of the community and health care providers. Presented at: Second Conference of the African Health Economics and Policy Association
    • Bsc Uzochukwu
    • C Ogoamaka
    • O Onwujekwe
    Uzochukwu BSC, Ogoamaka C, Onwujekwe O. Removal of user fees for maternal and child health services in Enugu, South East Nigeria: experiences of the community and health care providers. Presented at: Second Conference of the African Health Economics and Policy Association. Saly, Senegal, 15–17 March 2011.
  • The sudden removal of user fees: the perspective of a frontline manager in Burundi. Presented at: Second Conference of the African Health Economics and Policy Association
    • L Musango
    • B Meessen
    • M Nimpagaritse
    • Mp Bertone
    15 Musango L, Meessen B, Nimpagaritse M, Bertone MP. The sudden removal of user fees: the perspective of a frontline manager in Burundi. Presented at: Second Conference of the African Health Economics and Policy Association. Saly, Senegal, 15–17 March 2011.
  • Free healthcare policy for under-fives and pregnant women in northern Sudan: findings of a review Presented at: Second Conference of the African Health Economics and Policy Association
    • S Witter
    Witter S. Free healthcare policy for under-fives and pregnant women in northern Sudan: findings of a review. Presented at: Second Conference of the African Health Economics and Policy Association. Saly, Senegal, 15–17 March 2011.
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