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

Poverty in Mauritania

Profile for 2000

46,3%

31,4%

PoorExtreme Poor

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

Mauritania Ministry of Health and Social Affairs

GTZ –Basic Health Care Project

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