financing png’s free primary health care...
TRANSCRIPT
Financing PNG’s Free Primary Health Care Policy:
Survey finding on user fees, funding and performance
Andrew Mako – NRI Project Manager
Colin Wiltshire – ANU Project Manager
Introduction • Survey teams visited 142 health facilities across 8 provinces
• Tracking two major expenditure reforms, including health function grant.
• Findings are relevant to informing the implementation of PNG’s free primary health care policy
2
PNG’s free primary health care policy
• Key policy for the PNG Government set out in the Alotau Accord
• Launched on 24 February, 2014
• Survey gathered data on all revenue raised at the health facility
3
4
35% 40%
44%
68%
0%
10%
20%
30%
40%
50%
60%
70%
80%
General consultation Domestic violence Tribal fights Births
Consultations offered free of charge and costs
1.62
23.5 25.68
15.71
K 0.00
K 5.00
K 10.00
K 15.00
K 20.00
K 25.00
K 30.00
General consultation Domestic violence Tribal fights Births
58% 55%
48%
33%
26%
17% 13%
8%
32%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
ENGA EHP ENB MOROBE GULF SANDAUN NCD WNB
Availability of baby books and percentage of facilities that charge
Availability
Charge
Average
• Baby book cost is K2.40, while paracetamol and amoxicillin is K1.30.
Huge variations in monthly user fees raised
6
1020
59
488
719
167
0
200
400
600
800
1000
1200
1400
1600
1800
ENB ENGA WNB MOROBE EHP NCD SANDAUN GULF
All
HC+
Aid Post
Avg All
Avg HC+
Avg AP
• Health facilities use these user fees to pay for some important services…
13% 14%
20%
13%
6%
1% 0%
13% 12%
18%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Own Budget User Fees RequestDistrict
RequestProvince
RequestChurch
Privatecontractor
Own Salary ReferralHealthFacility
Do notprovide
Other
Health Centres meet expenses for conducting health outreach patrols through...
26%
17%
5% 2% 4%
1% 2% 8%
23% 18%
0%5%
10%15%20%25%30%35%40%45%50%
Own Budget User Fees RequestDistrict
RequestProvince
RequestChurch
Privatecontractor
Own Salary ReferralHealthFacility
Do notprovide
Other
Health facilities normally meet expenses for transferring patients to referral health centre / hospital through...
13%
21%
4% 0%
4% 1%
6% 4%
39%
12%
0%5%
10%15%20%25%30%35%40%45%50%
Own Budget User Fees RequestDistrict
RequestProvince
RequestChurch
Privatecontractor
Own Salary ReferralHealthFacility
Do notprovide
Other
Health facilities normally meet expenses for having fuel for transport and generator
15%
23%
1% 2%
7%
0% 2% 3%
38%
8%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Own Budget User Fees RequestDistrict
RequestProvince
RequestChurch
Privatecontractor
Own Salary ReferralHealthFacility
Do notprovide
Other
Health facilities normally meet expenses for paying casual staff, such as cleaners and volunteers
6% 11%
14%
4% 8%
0% 3%
8%
33%
16%
0%
10%
20%
30%
40%
50%
Own Budget User Fees RequestDistrict
RequestProvince
RequestChurch
Privatecontractor
Own Salary ReferralHealthFacility
Do notprovide
Other
Health facilities normally meet expenses for basic maintenance of health facility and staff housing
12%
23%
8% 7% 8%
1%
8%
16%
8%
16%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Own Budget User Fees RequestDistrict
RequestProvince
RequestChurch
Privatecontractor
Own Salary ReferralHealthFacility
Do notprovide
Other
Health facilities normally meet expenses for picking up and delivering drugs or other health supplies
• User fees seem to be particularly important for health facilities to pick up and deliver drugs…
• There is some disagreement between the OIC and the community
about refusing treatment for those who cannot afford to pay.
39%
33%
18%
0%
11%
35%
26%
10%
18%
10%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
fee is exempted allowed to pay according toability
allowed to pay in kind unable to recievetreatment
something else happens
What happens when a patient cannot afford the user fee? OIC & community perspectives
OIC
User
• Patients refused treatment at health facilities differs based on
practices in each province
46%
27%
20%
14% 14% 14%
10%
6%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
EHP SANDAUN ENB WNB GULF NCD MOROBE ENGA
Patients are unable to receive treatment for failing to pay user fees: Community perspective
55%
67%
79%
75%
50%
69%
91%
79%
69%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
ENB WNB MOROBE SANDAUN EHP ENGA GULF NCD
Community perceptions of user fees at the health facility
TOO LOW
ABOUT RIGHT
TOO HIGH
AVERAGE
14
Funding received through budgets
15
34%
25%
19%
12%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Budget prepared Budget submitted Budget approved Funding received
• 41% of health centres submitted a budgets
• 25% of aid post submitted budgets
Average value of budgets submitted & received
16
63,771
45,467
107,500
31,645
9,567
77,254
K 0
K 20,000
K 40,000
K 60,000
K 80,000
K 100,000
K 120,000
All State Church
Budget Submitted
Budget Received
Funding received through direct payments
17
• Nine health facilities surveyed received direct funding
• Average funding received just over K71,000
• Seven were church-run and the two state-run but none were government grants except DSIP
• Medical equipment was the most common purchased goods
• Estimated value of items: Church - K78,600 ; State K20,200
18
36%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
EHP Sandaun ENB WNB Enga Morobe Gulf NCD
Funding provider purchased supplies or materials
All %
Avg
19
46% 49%
46%
29% 25%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Received programsupport
Requested support Very satisfied A little satisfied Not satisfied
Administered support for programs and activities
20
84%
52%
44%
36%
79%
55%
32%
18%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Outreach patrols Picking up drugs Patient transfer Maintenance clinic/housing
Administered support helps facility to carry out...
Church
State
Discussion: Implications for PNG’s
Free Primary Health Care Policy
• The implications of the policy will be
different across provinces because of
large provincial variations
• Highlight several important challenges
regarding the allocation and distribution of
subsidy payments to health facilities to
identify implementation issues
Focus
(i) Discuss whether total allocations of subsidies made through the free primary health care policy will be sufficient to cover user fees raised across the country
(ii) Discuss the costs associated with distributing subsidy payments to health facilities
(iii) Make comparison between the Tuition-Fee Free Education policy, and the Free Health Care policy to highlight lessons the health sector could learn
(i) Will the free primary health care policy offset fees raised from
patients?
• Before PEPE no data across a large sample, on user fees charged by
health facilities
• Total estimated user fees raised in 2012 was almost K12 million, more
than (K11 million) allocated by government for free primary health
care policy component
Estimates of user fees (Kina) raised across health facilities Facility type Avg user fees
raised
(per month/
facility) (Kina)
Number of health
facilities (WHO -
2010)
Total user fees
per month
(Kina)
User fees raised
in a year
(Kina)
Health Centre 567.71 201 114,109.71 1,369,308
Sub Health
Centre 854.26 428 365,623.28 4,387,479.36
Aid Post 169.47 2,672 452,823.84 5,433,886.08
Rural Hospital 1,033.33 14 14,466.62 173,599.44
Urban Clinic 538.47 69 37,154.43 445,853.16
TOTAL 3,163.24 3384 984,177.88 11,810,000
Gov’t funding for free health care policy
is insufficient, including for aid posts
• Aid posts raise fewer fees than other health facilities, but their large numbers mean that in total, most user fees are raised aid post level
• Aid posts are important in the rural health system
• Both State & Church-run facilities raise fees than receive
funding through budgets; and higher for church-run than
state-run facilities
• User fees are a more reliable and readily available
source of funding than funds received through budgets
User Fees and Funding Received (Kina) in 2012: Church/state, aid
posts/all other health facilities comparison
Facility type Health facilities
received funding
%
% Health facilities
collect user fees Average funding
received in 2012 Average user fees
collected in 2012
Church – HC+ 25 83 40946 6685
State – HC+ 21 78 5772 8338
Church - aid
posts 13 88 1325 1165
State - aid
posts 5 74 486 1452
• Cannot allocate Free Primary Health Care policy
funds equally across provinces, and facilities,
because some provinces already provide free
services while revenue raised from fees at
health facilities is widely variable across the
country
• To emphasis this point using survey data,
comparisons can be made between provinces
that regularly charge fees and those who do not
• Table shows user fees raised in ENB & WNB are greater
than Gulf and Sandaun Provinces. This indicates ENB &
WNB would need to receive more subsidy payments to
cover fees raised, while Gulf Province will not need to
receive much.
User fees raised (Kina) across four provinces in 2012 (11 months) –
absolute numbers
Facility type Average User fees raised in 2012
ENB WNB Gulf Sandaun
Church – HC+ 11275 8250 798 3256
State – HC+ 19938 9900 0 (None charged) 1375
Church - aid
posts 1128 2200 933 - (No
observations)
State - aid posts 1254 1826 330 312
How to allocate funds
(i) Allocate evenly subsidy payments but this approach is
flawed
(ii) User fees raised prior to policy taking into account of
survey data similar to PEPE could be considered, but
would disadvantage provinces with the policy before 2014,
e.g. Gulf and Sandaun Provinces
(iii) Needs basis using cost of service and internal revenue
estimate, give more to poorer provinces, but it’d not be
based on current fees charged and provinces like East and
West New Britain would receive less funding
(ii) How will subsidy payments for the
policy be distributed?
• Bank or provincial/district health office where
health workers can collect subsidy payments
from, or provincial/district health administrators
can deliver them to a network of health facilities
at a time.
• But for both cases, the costs of access will be
high
High cost of accessibility for aid posts • Significant differences across health facility type, but
higher travel times and costs for aid posts when
compared with health centres.
Travel distance, mode of transport and time to the nearest bank
Facility
type Distance to nearest bank (% of
health facilities) Mode of Transport (% of health
facilities) Average
travel time
(hours) Within 20
km 20-100
km Over 100
km Walk Vehicle Boat Plane
Health
Centre 38 18 44 15 59 32 9 4
Sub
Health
Centre 33 30 37 4 70 33 4 4
Aid
Post 30 12 56 9 54 44 9 7
Rural
Hospital 14 0 86 0 71 29 14 5
Urban
Clinic 81 13 6 0 100 0 0 1
Options for getting subsidy funds to health workers
(1) Use bank accounts, although more than 60 % of health
facilities do not have accounts, and cost to nearest bank is
high – K366.
Table 19: Distance travel time and cost to reach bank by province Distance to nearest bank (% of health
facilities) Traveling
time (hours) Cost of return
travel (Kina)
Within 20 20-100 Over 100 (inclu.transport,
food & accom.)
By Province
East New Britain 48 38 14 6 254
West New Britain 29 29 43 8 727
Morobe 30 10 60 16 496
Sandaun 11 0 89 14 848
Eastern Highlands 82 9 9 2 62
Enga 58 32 11 2 20
Gulf 0 0 96 18 456
National Capital District 75 13 13 2 2
ALL Average 38 16 45 10 366
(2) Distribute funds to health facilities on informal
arrangements, but it’d be less reliable, as financial
services are not readily accessible in every
province
• one round of distributing subsidy payments per
year would not effectively supplement how user
fees are collected and spent, as health facilities
collect small user fees and often
(3) Provincial and District supervisors distribute
funds directly to facilities, but visits must be regular
(iii) Why free health policy will not work
like free education & lessons
• Significant differences and lessons need to be
considered
• K11 million for free primary health care policy vs K376 million allocated to Elementary and Primary schools component (or K20mil. vs K600mil.)
• Further funding required but an appropriate mechanism needed first
• Schools seem to absorb large funding given existing governance mechanism, but health facilities may not due to governance void
Conclusion
• User fees are widely available, easily accessible
and reliable source of funding for health facilities
and are important for delivering front-line
services
• Widespread variation in funds provided to health
facilities - offsetting user fees based on any
formula designed at national level unlikely to
accurately subsidise health facilities
• Good policy intentions, but implementation risks weakening rather than strengthening the health system if subsidy payments do not reach health facilities
• Free primary health care policy subsidy (K11million) is lower than total average user fees collected (K12million).
• Tuition fee-free policy offers good lessons for free health care policy, but moving slowly and learning by trialling approaches to implementation might work.
• But this could conflict with political pressure, and could lead to either non-compliance or poorer quality health services delivered.