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April 26, 2011

A debate in Mali on ‘free’ health care

At a recent national conference on Free Care Policies organized by the Ministry of Health in Mali, one thing became clear: In the last six years, the Government of Mali has made increasing access to health services, particularly for the poor, a major priority.

The two-day conference, which was co-sponsored by MLI, brought together over 100 policymakers, researchers, and healthcare practitioners from both the central and regional levels of Mali. Presentations featured several studies conducted on Mali’s free care initiatives, including the decisions to provide free Caesarean sections in 2005 and to provide free malaria treatment to children under 5 in 2007.

One study in particular, which was supported by HS20/20 – a USAID funded program which intervenes in the areas of financing, governance, operations, and capacity building to strengthen health systems – evaluated the impact of the removal of user fees for Caesareans. The study results indicated that Caesarean rates were increasing and post-Caesarean and neonatal deaths were declining. Yet, according to the study, not all issues had been worked out: women of lower socio-economic status still had problems accessing the service.

“What we want to ensure is equity. These initiatives should not only increase access, but should ensure that the most vulnerable can and do benefit,” said Christine Sow, who leads UNICEF’s Child Survival Section and is the Chair of Mali’s Health Sector Technical and Financial Partners Working Group. 

The numerous studies presented at the March 31 –April 1, 2011 conference sparked a lively dialogue and debate among participants around the positive and negative effects of these policies; the challenges and costs associated with implementation; and questions around sustainability and whether these policies benefit the poorest.

When asked whether such policies can save lives, Timothee Gandaho, Team Leader for Maternal Health and Family Planning for Abt Associates in Mali, replied with a strong and definitive, “Yes.”

“In 2005, the Caesarean rates were below 1 percent of live births. Now they are at 2.3 percent. While Mali still has a long way to go to achieve MDG 5 (which calls for a dramatic reduction in the number of women dying during child birth), they have made important strides. The Caesarean rate has more than doubled and the percentage of facility deliveries has also increased since the implementation of this policy.”

One particular point kept being repeated throughout the two days: Nothing is free. Everything has a price. While free care may eliminate direct user fees at the point of service, there is still a cost to make those services available. Someone somewhere is responsible for payment. This inspired a broader conversation around issues of how to make sure programs are sustainable, and the importance of including free care policies within a broader health financing framework.

The studies also highlighted the need for good communication of these policies to the population. Allison Kelley, MLI Country Lead for Mali, made the point that “users need to be informed of exactly what the free care package covers. Direct costs for services may be covered by these policies, but indirect costs such as transport from the villages to the health center may not. Until these issues are addressed, major barriers to increasing access to services will continue to exist.”

Following the conference, a policy brief was developed summarizing the main findings, conclusions and recommendations.

In Mali