Thematic Review Understanding the Health Financing Landscape and Documenting of the Types of User Fees (Formal and Informal) Affecting Access to HIV, TB, and Malaria Services in West and Central Africa April 30, 2020 Submitted to: The Global Fund Submitted by: ICF Understanding the Health Financing Landscape and Documenting of the Types of User Fees (Formal and Informal) Affecting Access to HIV, TB, and Malaria Services in West and Central Africa Table of Contents Acknowledgements ............................................................................................................................. iii Acronyms ............................................................................................................................................. iv Executive Summary ............................................................................................................................. 1 Introduction .......................................................................................................................................... 7 Background .............................................................................................................................................................................. 7 Justification for the Study ..................................................................................................................................................... 7 Intended Use of the Study ................................................................................................................................................... 7 Definitions ................................................................................................................................................................................ 7 Objectives ............................................................................................................................................. 9 Methodology ......................................................................................................................................... 9 Study Design ............................................................................................................................................................................ 9 Desk Review.......................................................................................................................................................................... 10 Web-Based Survey ............................................................................................................................................................... 11 Secondary Data Analysis .................................................................................................................................................... 11 Qualitative Data Collection ............................................................................................................................................... 12 Limitations.............................................................................................................................................................................. 13 Findings ............................................................................................................................................... 14 Research Question #1: Sources of Health Financing .................................................................................................. 14 Research Question #2: Health Financing Gaps ............................................................................................................ 21 Research Question #3: Health Financing Structure ...................................................................................................... 8 Research Questions # 4 and #5: User Fee Policies and User Fees Assessed ...................................................... 11 Research Question # 6: User Fee Revenue .................................................................................................................. 23 Research Question # 7: User Fee Implementation ..................................................................................................... 25 Research Question #8: Social Protection Mechanisms .............................................................................................. 28 Research Question #9: Effect of Social Protection on Utilization ........................................................................... 30 Research Question #10: Barriers to Utilization ........................................................................................................... 31 Research Question #11: Gaps in Access to Care ....................................................................................................... 41 Research Question #12: Removing User Fees ............................................................................................................... 3 Conclusions ........................................................................................................................................... 3 Recommendations ................................................................................................................................ 6 Bibliography ........................................................................................................................................ 13 Appendix A: Concentration Curves for Specific Service Utilization Indicators ........................... 31 Appendix B: Benin Country Report Appendix C: Cameroon Country Report Appendix D: Chad Country Report Appendix E: Cote d’Ivoire Country Report Appendix F: Gambia Country Report Appendix G: Guinea Country Report Appendix H: Mali Country Report Appendix I: Sierra Leone Country Report Appendix J: Togo Country Report ii Understanding the Health Financing Landscape and Documenting of the Types of User Fees (Formal and Informal) Affecting Access to HIV, TB, and Malaria Services in West and Central Africa Acknowledgements This study was conducted by a team from ICF and University College London. The study team wishes to thank the Health Financing Team at the Global Fund for their leadership and guidance in implementing the study, as well as country teams for their support and inputs. This work would not have been possible without support from Country Coordinating Mechanisms in each of the 23 WCA countries, and we acknowledge and thank them sincerely for their contributions. iii Understanding the Health Financing Landscape and Documenting of the Types of User Fees (Formal and Informal) Affecting Access to HIV, TB, and Malaria Services in West and Central Africa Acronyms ANC antenatal care ARI acute respiratory infection CAR Central African Republic CCM country coordinating mechanism DHS Demographic and Health Survey DRC Democratic Republic of Congo IPTp intermittent preventive treatment in pregnancy MOH Ministry of Health NGO nongovernmental organization NHI national health insurance OI opportunistic infection NSP National Strategic Plan OOP out-of-pocket PBF performance-based financing PEPFAR President’s Emergency Plan for AIDS Relief PMI President’s Malaria Initiative SP sulfadoxine/pyrimethamine TB tuberculosis UHC universal health coverage WCA West and Central Africa WHO World Health Organization iv Understanding the Health Financing Landscape and Documenting of the Types of User Fees (Formal and Informal) Affecting Access to HIV, TB, and Malaria Services in West and Central Africa Executive Summary Context To achieve the Global Fund’s ambitious objective of ending the HIV, tuberculosis (TB), and malaria epidemics, people, especially key and vulnerable populations, need increased access to quality health services. Over the past two decades, the global community has increasingly acknowledged that user fees for health care services are a barrier to accessing health services, especially in West and Central Africa (WCA), where user fees are a predominant feature of health systems as a result of the Bamako Initiative. In an effort to better understand how user fees impact access and utilization of health services in WCA, the Global Fund commissioned a regional study to investigate how health financing structures and user fees in particular are affecting access to and utilization of HIV, TB and malaria services, and the implications for health systems of removing or revising these types of fees in 23 countries in WCA.i The Global Fund contracted with ICF in 2019 to carry out the study, which uses a mixed-methods approach to answer 12 research questions. The study methods consisted of desk review and a web- based questionnaire in all 23 countries as well as secondary data analysis of household surveys and primary qualitative data collection in 9 priority countries (Benin, Cameroon, Chad, Cote d’Ivoire, Gambia, Guinea, Mali, Sierra Leone, and Togo). Primary data collection consisted of key informant interviews at national and sub-national levels, and focus groups with community members and exit interviews with patients in approximately three health facilities in each country. Data were collected between October 2019 and February 2020. Findings Sources of Health Financing In most WCA countries, health financing landscapes are characterized by low government expenditures high out-of-pocket (OOP) expenditures by households, and high external donor support. In 2017, the percentage of total health expenditures that came from OOP payments ranged from 14% in Sao