User fee exemption policies in Mali: sustainability jeopardized by the malfunctioning of the health system

Abstract

In Mali, where rates of attendance at healthcare facilities remain far below what is needed, three user fee exemption policies were instituted to promote access to care. These related to HIV/AIDS treatment, as of 2004, caesarean sections, since 2005, and treatment of malaria in children under five and pregnant women, since 2007. Our qualitative study compared these three policies, looking at their implementation provisions, functioning and outcomes. In each healthcare facility, we analysed documentation and carried out three months of on-site observations. We also conducted a total of 254 formal and informal interviews with health personnel and patients.While these exemptions substantially improved users' access to care, their implementation revealed deep dysfunctions in the health system that undermined them all, regardless of the policy studied. These policies provoked resistance among health professionals that manifested in their practices and revealed, in particular, the profit-generation logic within which they operate today. These dysfunctions reflect the State's incapacity to exercise its regulatory role and to establish policies that are aligned with the way the health system really works.

When things fall apart: local responses to the reintroduction of user-fees for maternal health services in rural Malawi

“…This generates a cascade of dynamic responsesbehaviours and relationships arising from within and outside the health systemin relation to policies, 7 which ultimately result in the exclusion of the most vulnerable rural women from maternity care services, against the aim of global and national safe motherhood policies. This ethnographic study supports a growing body of evidence regarding the inequitable effects of user-fees, 8,9,10 problems in relation to "traveling models" (uniform interventions which "travel" from global to local levels) such as skilled birth attendance and user-fee exemption policies, 11,12,13 and the role of multiple actors in the generation and mitigation of problematic policies and their effects. In this way, we illuminate processes leading to inequity, a central challenge to achieving the Global Strategy for Women's, Children's and Adolescents' Health and the Sustainable Development Goals (SDGs).…”

“…11,35,36 Our analysis shows how dynamic responses and accountability relationships 24 can help explain problems with the implementation of policy 36,37 and their inequitable effects when confronted with broader malfunctions of health systems. 12,13,35 This article contributes to understanding processes leading to inequity, which is a central challenge to achieving the Global Strategy for Women's, Children's and Adolescents' health and the SDGs. 14 Global attention to maternal health has contributed to holding governments responsible for maternal mortality and improving health systems' capacity to provide services.…”

The emergence of the national medical assistance scheme for the poorest in Mali

“…However, several user fee exemption policies (HIV in 2004, caesarean in 2005, anti-malaria for children and pregnant women in late 2006) have been put in place, decisions which were highly political and technically contested in their formulation [27]. Championed by the Health Ministry and widely supported internationally [3], these initiatives occupied the forefront of the political scene and attracted widespread attention, eclipsing the development of the social protection system and health cover for the poor.…”

“…Faced with the challenge of nancial accessibility, Mali put in place several user fee exemption policies from 2000 to 2010, primarily for caesareans, HIV-related care and anti-AIDS treatment for children. However, these policies were not as effective as had been hoped [26] and the di culties linked to implementation and funding remain considerable [27]. Recourse to healthcare for the sick is still just as low and the most disadvantaged still experience major di culties obtaining treatment in the formal sector given the numerous barriers they have to overcome, primarily nancial ones.…”

“…Imposed without any consultation by the country's highest authorities, the latter are in fact particularly poorly received by health professionals and even considered harmful to the viability of the health structures and the personal interests of professionals. Furthermore, the health professionals believe that the structuring of these policies in relation to social protection mechanisms has not been su ciently considered or planned in advance by those responsible [27,59]. The AMO therefore appears to be the least bad option for health professionals, provided that it is possible for its implementation conditions to be negotiated.…”