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Operational Research on
Health care for the poorestHealth care for the poorest
Mauritania Ministry of Health and Social Affairs
GTZ –Basic Health Care Project
Objectives
Description of our strategy General situation The Challenges Contextual Opportunities Implementation Results and lesssons learned
General Situation
Area: 1.030.700 sq km
Population: 2.912.584 (July 2003)
Mostly living in Nouakchott, Nouadhibou and the southern Senegal river area
Climate: desert, constantly hot, dry and dusty
Economy: agriculture and livestock
iron
rich fishing area
oil 2005?
The country : Islamic Republic of Mauritania
General Situation
Development policy in the Islamic Republic of Mauritania
In general
Since 2001 Poverty Reduction Strategy Paper
Consistent donor support through the HIPC initiative
In the health sector Midterm Budgetary Framework 2002 – 2004
3 main additional objectives:
1.1. TO IMPROVE THE HEALTH INDICATORS OF THE TO IMPROVE THE HEALTH INDICATORS OF THE POPULATION AND MORE SPECIFICALLY THOSE OF THE POPULATION AND MORE SPECIFICALLY THOSE OF THE POOREST GROUPS OF SOCIETY.POOREST GROUPS OF SOCIETY.
2.2. TO LIMIT THE IMPACT OF HEALTH EXPENSES ON THE TO LIMIT THE IMPACT OF HEALTH EXPENSES ON THE HOUSEHOLD BUDGETS OF THE POOREST.HOUSEHOLD BUDGETS OF THE POOREST.
3.3. TO IMPROVE THE PARTICIPATION OF THE POOR IN THE TO IMPROVE THE PARTICIPATION OF THE POOR IN THE MANAGEMENT OF THEIR HEALTH SERVICES.MANAGEMENT OF THEIR HEALTH SERVICES.
General Situation
Responsibilities Develop policies Develop laws Coordinate and monitor activitiesTarget groups Socially deprived Handicapped persons Children with problemsToolsNeedy Certificate (local government)
Ministry of Health and Social Affairs
ORGANIGRAMME
Direction for Social Action Direction for Sanitary Protection
Regional Direction for Health and Social
Promotion
Regional Service for Social Action
Responsibilities• Social support of the poorest• Support to the local government social services
Regional Hospital
Health Centre
Health Post
The Poor and the Health services
There is a part of the population that is very poor, badly defined and therefore badly served by public health services.
Health care not accessible There is no efficient strategy defined by the
health and social affairs department to take care of these people
Only an approach by social groups (handicapped, …) or a pragmatic, case by case approach of the health staff
The Challenges
To offer the poorest of the poor access to quality health services.
Key questions: What is “Being poor”? Who determines who is poor? How to pay for their health care?
Problem of access to care for the ‘needy’
POVERTY, EXTREME POVERTY
Absence of an efficient social strategy
Concept
Efficient social strategy(acceptable, everlasting)
Context
Concept Context
Our Strategy Loss of traditional social relations Loss of existing, traditional social backup Insufficient rural production Inefficiency of the new
institutions to deal with the poor
Inefficiency of the new institutions to deal
with the poor
Protection of health and assistance to ill peopleProtection of health and assistance to ill people Solidarity between Muslims redistribution of wealth from the rich to the poor
Zaakat = solidarity tax : 2,4%
The contextual opportunities (local actors)
General principle:
« It is obligatory to preserve his own health
and the health of others »Attitude of the Muslim towards ill people recommended by the texts:
Support and assistance Act against stigmatisation (wrongful act) Compassion Material support moral support
One of the pillars of IslamAlms, charity =
obligatory for each Muslim whose belonging are more important than a certain level.
Wealth has been accorded by Allah and does not belong to the Muslim.
IslamIslam
HealthHealth PovertyPoverty
1. Islam religion of the entire population and source of the national law system
contextual opportunities
Decentralisation:Decision and use of
resources at the peripheral level
2. The state
The political will to
improve living conditions of the
poor An important increase of the
budget (x 6)
Contextual opportunities
Democratisation of the country emergency of social society
Local government has a responsibility to support the ‘needy’ and the health system
Specified in the official government declarations and in the
budgetary allocations.
3. Local government or community
Building alliances
Looking for a consensual definition
Participative approach to develop and write the project
Setup of a Coordination Committee regrouping the ministry of interior, the ministry of health and social affairs, the secretary of state for women affairs, the commissioner for human rights and the fight against poverty and religious organisations (rabita, …).
Implementation
The placeThe place17 pilot sites, around the health structures in the 17 pilot sites, around the health structures in the
regions of Hodh El Gharbi and Hodh Echargui.regions of Hodh El Gharbi and Hodh Echargui.population : 84.183 habitantpopulation : 84.183 habitant
Regional hospital: Regional hospital: 22 Health centre: 5Health centre: 5 Health Post:Health Post: 12 12Start of the processus: 1/ 2003Start of the processus: 1/ 2003Start of the assistance: 6/ 2003Start of the assistance: 6/ 2003
Implementation
Definition of the ‘needy’ CONSENSUAL AND CONTEXTUAL
Definition (consultant + seminar): « Needy is the situation in which a person, although he may be able to satisfy an elementary need for food, is potentially not able to pay for essential medical care»
An operational form of the definition :«Needy is the situation in which a person is not able to satisfy an elementary need for food (Sed Ramagh), … »Base : notion ‘FOOD’: criterion used in some modern definitions of poverty
criterion used by the Islam case law (Figh)
Implementation
Identification:
PROXIMITY AND REPRESENTATIVITYA. Setup of the committees:
Composition:Choice of the members :Choice of the members : •independent of the health services•only directive to involve religious leaders and members of local governmentDifferent compositions :Different compositions :•members of traditional and religious organs (imam, faghih, village chief, …) •community organisations (local government, health committees, …)•staff of the health infrastructures
Tasks:•to identify the ‘needy’ on the basis of the consensual definition•to collect resources at the local level to pay for health care for the ‘needy’•to manage these resources
Interaction with the Regional Direction for Health and Social Affairs:* Regional Service for Social Action: support and control* Responsible of the health services: close collaboration
Implementation
B. Elaboration of the lists of the ‘needy’ (by the committees)
Who? every adult person corresponding to the definition and not taken in
charge by a third person every child below 18 depending on those adults
How? proposition by a committee member decision by whole the committee establishment of the lists validation by the Regional Service for Social Action control of the lists
door-to-door survey of 10% of the people on the lists >80% should be conform to the definition
Recommendations to the Identification committee
Identification:
Implementation
C. ‘Needy’ certificate
Signed by the president and signed by the Regional Service for Social Action Nominative The only justification for free access to health care
Identification:
Implementation
Financial resources :
Regional Hospital and : 10% of the hospital State budget
Health Centre 10% of health centre State budget Budget of the local government - as much as they can contribute Contribution of the population 1. « Zaakat , Sadagha…» - Fatwa
2. 10% of the Cost recovery benefice
Health Posts: Budget of the local government, except in certain posts to test the influence of
external (state!) funds Contribution of the population (Zaakat + cost recovery + private)
Implementation
Care package : Care in the public health services (from the health post up to Nouakchott) Medicines bought in private pharmacies, only if not available in the public
system Transport to and from the reference level for the needy and one accompanist
On the basis of a contractThe communities commit themselves to pay for care at the level of the health post
(deter communities from inflating the beneficiaries lists)
The state budget compensates for additional costs at the referral level.
Implementation
Circuit of assistance to the ‘needy’ patientTwo options : With card care Without card:
- no emergency referred to identification committee
- emergency supported by the facilities’ own funds
Results
Population ‘needy’ : 8 516 persons
Percentage ‘needy’ : 11 % (much below the figure of 31,4%)
Beneficiaries (3 month) : 996 ‘needy’RH : 45Health Centre :524Health Post :427
0,5 contact/needy/ year0,5 contact/needy/ year
70%
30%
Adults
Children
A. Identification
Composition of the ‘needy’ population
75%
25%
Adult women
Adult men
Results
0
50000
100000
150000
200000
250000
300000
350000
RH HealthCentre
HealthPostS
HealthPostW
State
community
cost recovery
local gov
Contributions/ source/ month
300 ouguiya = US$1
Results
0%
20%
40%
60%
80%
100%
RH HealthCentre
HealthPostS
HealthPostW
Transport
Private Pharmacie
Health service
Expenses
Lessons learned
Muslim society The Koran and the Islamic case law contain solidarity mechanisms aiming at the redistribution of wealth in favour of the ‘needy’: Zaakat, wagf, charity, religious legacy, …
Taking care of the ‘needy’ is not expensive average cost is at 1004 UM which is about 3 EURO
Lessons learned
Communities are capable of managing their ‘needy’ if they are given the necessary responsibility and support empowerment
Managing things at the local level allowed for a more acceptable identification and a more transparent management social control
Perspectives
Monitor and evaluate the pilot experiment
Reinforce collaboration with the commissioner for human rights and the fight against poverty to find solutions for border-line cases
Progressive extension of the model in the other regions of the country
Document the research scientific backup
Results:
circuit of the Needy Patient
WITHOUTCARD
WITHCARD ENROLLMENT DIAGNOSIS
REFERRAL
MEDICINES OR CARE
AND/OR
NO EMERGENCY
NOT TAKEN IN CHARGE ON THE ‘NEEDY’-MONEY
« NEEDY »
REFERRAL TO A COMMITTEE SESSION TO DECIDE IF REALLY ‘NEEDY’
REIMBURSEMENT
WRITTEN PROMISE TO PAY
TAKEN IN CHARGE
DECLARES TO BE ‘NEEDY’
TAKEN IN CHARGE
EMERGENCY