Obtaining sufficient resources for health and eliminating barriers to accessing health services, especially for the most vulnerable populations, is a major objective for West African civil society, meeting recently in Abidjan, with a view to strengthening the advocacy capacities of its actors.
The workshop co-organized by ASAPSU, an NGO based in Ivory Coast and CICODEV Africa of Senegal, was attended by 33 participants from 6 different countries: Ivory Coast, Mali, Benin, Senegal, Burkina Faso and Belgium.
The objective of the meeting was to assess the state of health financing and Universal Health Coverage (UHC) in the sub-region; to identify (UHC) financing options in sub-regional countries and their potential impacts (State: Budgetary Space, Communities: Endogenous Health Financing Mechanisms, International Cooperation: Official Development Assistance, Private Sector: Corporate Social Responsibility); and to identify avenues for advocacy on financing options at the national, regional and international levels.
The Executive Director of CICODEV Africa gave the welcome address and addressed the context of health financing in West Africa. In his presentation, he pointed out that none of the signatory states of the Abuja agreement had reached the target of 15% of the budget to be allocated to the health sector. The National Health Accounts (NHA) of our different countries reveal the contributions of the actors: more than 50% of health expenditure is borne by households. The financing strategies set out by our States use mechanisms such as incoming calls, sin tax, and air tickets. These mechanisms suffer from 2 shortcomings: their mobilisation (competition from new technologies, crank reversal and inconsistencies in public policies creating a cobra effect) and their allocation to health (single fund).
He pointed out that discussions are underway within our countries to identify domestic sources to finance health, UHC and Social Protection by questioning the fiscal space without threatening our budgetary balances, known as domestic mechanisms. However, their sustainability is not guaranteed because they are beyond our control. Even though Public Aid for Health Development is increasing and being marketed in the form of public-private partnerships (PPPs), it runs the risk of taking us back to square one with a two-speed medicine that is a potential source of exclusion. On the other hand, when we take a closer look at the National Health Accounts (NHA), one constant is obvious on an objective reading: the household share is the highest of all sources of health financing (on average 55% in our countries).
According to CICODEV’s Executive Director, civil society’s approach today is inspired by this: we need to ask ourselves how households care for themselves, and how communities organize themselves to care for themselves. This is what we call Endogenous Health Financing Mechanisms (MEFS). They are rooted in the sociological experience of the communities. They are controlled by the communities and have often survived the test of time. The only village in Senegal that has achieved universal health coverage did so when the village chief granted a field to the villagers saying “let’s cultivate it, sell it and use the produce to enroll in mutual health insurance”.
Serious reflection and a determined option to identify these MEFS, consolidate them, promote them, give them formal recognition and link them to our public health financing policies would bring added value. The MEFS would consolidate the social and solidarity economy, which is the primary source of resilience in our societies. They would give a breath of fresh air to our countries whose budgets are bending under the weight of the urgent necessity of a demanding social call for social protection.
We must therefore get off the beaten track and move the lines where we have a chance of winning the battle for control of our development levers. The objective observation of NHAs in the health sector directs us towards households. How, without increasing the burden beyond our current levels, can we broaden this contribution base, distribute it more equitably and make it sustainable? This work is certainly the State’ s mission, but it is the prerogative of society, of our communities along with the diversity of their organizational forms, including the civil society actors that we are represented by (ASAPSU in Ivory Coast, APROSOC in Benin, CICODEV in Senegal) who have been engaged in this battle for more than 3 years now and with our colleagues in Burkina Faso and Mali.
CICODEV’s Health Policy and Advocacy Officer followed the Executive Director’s lead in portraying the state of health financing in the West African sub-region. In his presentation, he emphasized the importance for countries in the sub-region to have a healthy population as it promotes economic development, resilience and prosperity. For this reason, many governments have embarked on the path towards universal health coverage (UHC). The international community, national governments and many private organizations and individuals are converging on the principle that universal access to health care is a goal that merits increased financial investment.
The study presented by the Policy and Advocacy Officer showed that while illness is a major initial shock to families, the out-of-pocket payment it generates is a major economic cause, pushing households into poverty. In some countries, the direct payment component is often responsible for catastrophic expenditures. For example, health systems that rely primarily on out-of-pocket payments to finance their operations become partly responsible for impoverishing populations. One of the solutions discussed to improve access to care for this section of the population has been to remove part of the financial barrier to access to care by trying to abolish direct payment.
Following the example of other West African countries, Ivory Coast, Benin and Senegal have undertaken reforms that have, at certain levels, improved the functioning of their respective health systems. However, these reforms have had a negative impact on the financial accessibility to health care for the majority of the populations who do not benefit from social insurance systems in general, and for the poorest in particular. However, the three countries have decided to provide an appropriate response by setting up Universal Health Coverage (UHC) projects. These different projects combine or aim to pool public funding, social insurance and community insurance mechanisms to ensure that funding is capable of meeting the expectations of the populations.
Despite these State responses, analysis of accounts at the sub-regional level shows that households pay a higher proportion of health expenditure. Household contributions are the primary source of health financing (43% in Benin), (48.11% in Côte d’Ivoire) and (58% in Senegal). Despite the efforts made by the respective governments, their contribution remains modest, averaging around 24%. The external contribution also remains low, although in Benin it reaches 25%; a general observation in almost all West African countries. This trend in health financing in the three countries is a form of impoverishment of the populations. It is up to the various governments to reverse the trend and find less impoverishing mechanisms for the populations. The analysis shows that the budget of the Ministry of Health in the three countries remains low (less than 6%) over the last five years despite efforts by the governments of the three countries to increase resources for the health sector. This shows that additional efforts need to be made to mobilize additional resources for the health sector.
It is therefore necessary for governments to encourage and promote internal initiatives that can mobilize domestic resources. CICODEV’s Policy and Advocacy Officer presented that health financing in general “suffers” from a lack of real ownership by state authorities. All the more so as households bear the major share (from 40 to 53%) of health expenditure in sub-regional countries ( Ivory Coast, Benin, Senegal) which are impoverished due to the direct payment system. States invest in health personnel and the administration of health services rather than investing in the population’s primary health care. This is why civil society has decided to advocate to reverse this trend.
To think outside the box, CICODEV Africa had invited the Director of Legal Affairs and Partnerships of the National Agency for Universal Health Coverage (ACMU) of Senegal, who made a presentation on fiscal space.
In its simple expression, fiscal space is “the margin that allows the government to allocate resources to pursue an objective without jeopardizing the viability of its financial position or the stability of the economy”. The basic idea is that the government must have or create fiscal space if it is to allocate additional resources to useful spending. It can create it by raising taxes, obtaining grants from abroad, reducing non-priority spending, borrowing from domestic or foreign creditors, or borrowing from the banking system (thereby increasing the money supply). However, it must do so without jeopardizing macroeconomic stability and fiscal sustainability by ensuring that it can finance the necessary spending in the short and longer term while servicing its debt. (P. Heller, IMF, Finance and Development, June 2005).
He presented some very relevant examples of how to assess health needs, proposed fiscal and parafiscal options involving the creation of taxes on certain products such as tobacco, beverages and alcohol that have been put in place by WAEMU and ECOWAS and are being applied in some countries such as Senegal.
These taxes applied to the most harmful products would make it possible to increase the health budget. To do so, only genuine action by civil society will have an impact. It emerged from the various interventions that fiscal space should be used to finance health in our countries through the introduction of a social VAT and the creation of new taxes on culinary broths and wicks. Acceptance by the populations of these new taxes requires awareness-raising and communication on the part of civil society.
In order to stir the pot, CICODEV has also considered EURODAD’s Policy and Advocacy Manager’s reflections on trends in Official Development Assistance (ODA). Eurodad (European Network on Debt and Development) is a network of 50 civil society organisations (CSOs) from 20 European countries and is an advocacy and research structure on issues related to ODA.
Official Development Assistance has been approached in terms of unique financial resources in that it contributes to the achievement of sustainable development objectives, finances public policies (accountability) and remains flexible. It also constitutes a determining force with neo-liberal and austerity policies in donor countries, which advocate the market as a vehicle for development and the use of aid for security and migration objectives.
The presentation by Eurodad’s Policy and Advocacy Manager provided an understanding of the technical aspects of ODA with Public-Private Partnership (PPP) contracts, which are long-term contractual arrangements in which the private sector provides infrastructure and services that were traditionally provided by the public sector, such as hospitals, schools, roads, railways, water and sanitation. PPPs are increasingly being promoted as a solution to the financing gap needed to achieve the MDGs (Agenda 2030). Donor governments and financial institutions have put in place multiple initiatives to promote changes in national regulatory frameworks to facilitate the introduction of PPPs.
Analysis by Eurodad’s Policy and Advocacy Manager shows that PPPs are the most expensive method of financing and are generally very risky. It is riskier for the state than for the private companies involved, as the public sector has to step in and bear the costs when things go wrong. PPPs are very complex to negotiate, implement and monitor. PPPs are often renegotiated, which means an increase in the total cost of the project. In the view of the EURODAD expert, the PPP system does not promote the participation of local communities or public scrutiny and is a system that lacks transparency. PPP contracts are subject to commercial confidentiality issues. They often have a negative impact on the poorest and contribute to increasing inequalities.
The expert presented the main ODA actors (European Union, Global Fund, World Bank and OECD) and the mechanisms put in place by the different structures for financing the fight against poverty and especially health financing through the GFF (Global Financing Facility). In the exchanges, it emerged that a deepening of technical knowledge of the agenda and contents of the main donors’ programmes would enable civil society to perfect their advocacy strategy in relation to ODA.
In conclusion, the presentations and discussions allowed civil society to make strong recommendations to improve the financing of health systems in West Africa.
– The workshop advocated the recognition and valorization of endogenous health financing mechanisms by state authorities in the health financing circuit;
– The workshop suggested that civil society should play its role as a sentinel in monitoring and following up on the commitments made by our governments, TFPs and the private sector in health financing;
– The workshop recommended that civil society organise capacity building sessions at the regional level on citizen monitoring, surveillance and control;
– The workshop recommended that research and studies be conducted in a participatory manner on the fiscal space in each of the countries present at the session in order to explore all the possibilities of state financing for the health sector;
– The workshop suggested the sharing of experiences in health financing at national, regional and international levels;
– The workshop proposed the creation of advocacy poles for access to health care in the sub-region.