Free healthcare initiative in Niger makes health gains but many challenges remain
In March this year, the Nigerien government organised a conference to discuss the impact and challenges of its free healthcare initiative for women and children. The conference brought to the fore the remarkable health gains that the initiative has achieved since it was introduced in 2005, but also highlighted the acute funding challenges that are threatening the sustainability of the scheme.
Niger has one of the worst maternal and child mortality rates in the world. According to the World Health Organisation (WHO), one in every 23 Nigerien women will die during pregnancy or child birth (compared to 1 in 42 for the Africa Region), only a fifth of births are attended by skilled health workers, and only 46% of pregnant women will benefit from antenatal care. What is more, one in every seven children risks dying before their 5th birthday.
In light of such startling statistics, it is laudable that the government of Niger introduced a free healthcare policy to alleviate the financial burden of accessing health care for women and children. Under this initiative, women are entitled to free contraceptive services, antenatal care, deliveries including caesarean sections, and free treatment for breast and uterus cancers. Children under-5 are entitled to receive a wide range of health services free of charge, including consultations, surgery, medicines, and laboratory tests.
The March 2012 conference coincided with the release of findings of an evaluation of the free healthcare programme, which showed impressive health achievements. In just 5 years, uptake of antenatal services has more than doubled from just under 38% in 2004 to 90% in 2009. Use of modern contraceptive methods also increased from 5% in 2006 to 16% in 2010, while the number of C-sections also increased from 0.8% to 2.8% during the same period. The evaluation revealed that as financial barriers were lifted, uptake of health services by women and children rose and there was a drastic reduction in self medication and use of traditional medicine.
In spite of the progress made so far, the free healthcare initiative is threatened by acute funding shortfalls creating fears that it may be scaled back. Between 2007 and 2011, the average annual budget allocated to the initiative was 4 billion CFA francs (US$7.8 million) (see Figure 1), which is only about half of what was needed to fully implement the programme. Although government allocations for the initiative improved slightly in 2011, the funding shortfalls of the previous years have created huge unpaid healthcare bills (amounting to around US$41.4 million as of March 2012), which has affected the ability of health service providers to deliver services to beneficiaries. Many healthcare providers that operate under the programme experience frequent stock-outs of medicine and medical consumables which compromise effective utilisaiton of care by beneficiaries.
The funding challenges are partly due to the failure of policy makers to properly assess the financial requirements of the initiative and to put measures in place to fund it. Also, donor support has been disappointingly low, including from agencies that encouraged the government to adopt the free health care policy in the first place. So far, only the French Development Agency has proposed to reimburse a fifth of the cost of the initiative as well as UNICEF who occasionally provide some financial support. Improved donor support, both technical and financial, will be crucial to enable the government to scale up the initiative and assure its sustainability.
A further challenge has been the lack of accountability and transparency in the management of funds, with cases of inaccurate invoicing and double payments widely reported. Health workers have also complained of increased workload without adequate compensation. And although the majority of health providers support the free health care initiative, they are worried it is not properly implemented leaving them to pick up the pieces.
The evaluation also notes that while the initiative has brought benefits to women and children, healthcare user fees for the rest of the population are still very high. The WHO estimates that out-of-pocket payments account for 41% of total health expenditure in Niger – more than twice the recommended rate of 15 – 20%. Given that around 70% of Nigeriens live on less than US$1 a day it is clear that low levels of financial protection will be affecting millions of people, driving the poorest households into deeper levels of poverty and denying them access to essential health care.
The recommendations that came out of the conference were clear and it is important for government to take these seriously. In particular the government should look to increase its allocations for the health sector, especially to the free health care initiative, and for the Ministry of Health to settle the arrears that are owed to health service providers. In order to increase revenue, government should consider using innovative financial measures such as raising VAT on luxury products, and taxing the telecommunication, alcohol and tobacco sectors. In the immediate term donor agencies should step up their support to the government of Niger so that funding shortfalls do not undermine the significant progress made so far.