Local sustainability and scaling up for user fee exemptions: medical NGOs vis-à-vis health systems

Abstract

Free healthcare obviously works when a partner from abroad supplies a health centre or a health district with medicines and funding on a regular basis, provides medical, administrative and managerial training, and gives incentive bonuses and daily subsistence allowances to staff. The experiments by three international NGO in Burkina Faso, Mali and Niger have all been success stories. But withdrawing NGO support means that health centres that have enjoyed a time of plenty under NGO management will return to the fold of health centres run by the state in its present condition and the health system in its present condition, with the everyday consequences of late reimbursements and stock shortages. The local support given by international NGOs has more often than not an effect of triggering an addiction to aid instead of inducing local sustainability without infusion. In the same way, scaling up to the entire country a local pilot experiment conducted under an NGO involves its insertion into a national bureaucratic machine with its multiple levels, all of which are potential bottlenecks. Only experiments carried out under the "ordinary" management of the state are capable of laying bare the problems associated with this process. Without reformers 'on the inside' (within the health system itself and among health workers), no real reform of the health system induced by reformers 'from the outside' can succeed.The problems relating to the sustainability of public policies in Africa, especially when the policies benefit from development aid, in the area of health among others, are familiar to researchers and policy-makers. However, as far as user fee exemptions are concerned, debates about these problems have extended well beyond the narrow circle of experts and into the public domain in the countries concerned. Throughout our research, we have observed that the sustainability of free healthcare policies is a major concern of all the actors (health workers, users, managers and senior administrative staff), and an issue that has generated widespread scepticism, especially in Mali and Niger [1,2]. There is general unease about the state's ability to reimburse health centres and to provide essential inputs. The scepticism is fuelled by a two-fold negative experience: decades of incoherent public policies at national level, plagued by bad management and uncertain funding, on the one hand; and the endless U-turns by donors, the double binds of frequent contradictions in their funding policies and the short-term nature of the programmes they enact, on the other [3].The first years of exemption policies, which were beset by late reimbursements and more or less chronic stock shortages, only added to the scepticism. The disquiet appears to be justified: despite their positive impact in terms of health centre attendance, without funding guaranteed over time, efficient management, secure supply channels and motivated staff, free healthcare policies fall foul of a host of adverse effects at every level of the health pyramid.

Evaluation of regional project to strengthen national health research systems in four countries in West Africa: lessons learned

“…In most of these countries, the context was one of limited number and quality of human resources, high turnover rates, motivation problems, and bureaucracy. These factors are known to contribute to low performance in most developing countries [39–45], and are more pronounced in post-conflict countries [46–53]. The existence of these factors affects project implementation and suggests that short-term projects cannot strengthen all NHRSs, especially in post-conflict countries.…”

Barriers and facilitators in the implementation of bio-psychosocial care at the primary healthcare level in South Kivu, Democratic Republic of Congo

“…Providers from HCs are indeed used to execute activities decided and financed by outsiders, similar to what is observed in other parts of Sub-Saharan Africa. 21 The resources from donors are given to managers of health zones who, in turn, finance certain activities planned in HCs. In this context, a HC without autonomous resources is not able to easily initiate and pilot a contextual change approach, inspired by the experience of the staff.…”

A conceptualisation of scale-up and sustainability of social innovations in global health: a narrative review and integrative framework for action

“…However, the spatial progression of the innovation is also relevant to sustainability. For example, one study [ 17 ], while drawing on the experience of non-governmental organisations (NGOs) with free healthcare Burkina Faso, Mali, and Niger, highlights two sustainability processes: one at the local level and one at a national level. These two processes show that sustainability begins at the pilot project level, where NGOs are often responsible for maintaining innovation.…”

“…Many conceptual frameworks used in global health aim to inform policymakers, donors, researchers, and implementers of best practices for scaling up and sustaining promising interventions. Nevertheless, they are normative or, in other words, standardised models and rules are proposed [ 17 , 20 ], with a focus on high-impact/immediate change [ 21 ]. Consequently, existing frameworks do not allow for a better understanding of how different functions and innovation processes interconnect and influence each other and what needs to be sustained in large-scale programmes and via which processes.…”