Removing Cost Barriers to Care

To achieve coverage goals among populations facing extreme poverty requires not only free LLINs, ACT, and SP, but also the removal of other accompanying direct and indirect cost barriers. Project Muso’s qualitative and quantitative research revealed that even in the context of free ACT, financial barriers still play the central role in delaying and preventing access to malaria care. A mother, deciding between feeding her family or paying the consultation cost to bring her febrile child to the health center for assessment of an illness whose care may or may not be free, will often choose to feed her family. The cost of health services poses a formidable barrier for many Malians. A parent, who knows that their child has a fever, cannot be sure that their child has malaria or another illness. Even though malaria drugs are now free for children under five, other direct and indirect costs still prevent these vulnerable populations from accessing ACT, including consultation cost, other diagnostic testing, and treatment for co-morbid diseases that account for or complicate a patient’s symptoms.

If the patients that CHWs refer cannot pay for their consultations, diagnostic tests, or complete prescriptions, their trust in the CHW and in the health system as a whole disintegrates. Subsequently, they may not follow through with referrals, seek early treatment from the CHW, or make future visits to the health center. Furthermore, since impoverished patients tend to seek care only at more severe stages of disease, their treatment is often more complex and expensive. When CHWs refer patients to the health center, patients must thus be able to access medical care equitably, regardless of diagnosis and ability to pay. Ensuring the human right to health care access is necessary to achieve rapid health services utilization and diagnosis and treatment of malaria cases within 24 hours.     

There is emerging international consensus that disease-specific initiatives must be integrated with broader efforts to achieve universal access to primary care by removing financial access barriers to care. The removal of user fees in settings where patients cannot afford to pay them has been recommended by leading international bodies including the World Health Organization, DFID, and the Global Campaign for the Health MDGs. As the World Health Organization’s 2008 World Health Report states:

“It is not acceptable that in low-income countries primary care would only deal with a few priority diseases… primary care requires adequate resources and investment, and can then provide much better value for money than its alternatives. It is not acceptable that, in low-income countries, primary care would have to be financed through out-of-pocket payments on the erroneous assumption that it is cheap and the poor should be able to afford it.”

Since 2000, ten countries in sub-Saharan Africa have reformed their health care financing systems to remove user fees for those who cannot afford to pay. 

Project Muso’s Solidarity Fund aims to increase early and consistent malaria prevention and treatment by removing direct and indirect access barriers to care. In the peri-urban area of Yirimadjo, while there are significant populations of patients who cannot afford to pay for care, there are also many patients who can afford to pay for care. In this context, an exemption system is appropriate to facilitate access for those who cannot afford to pay, and has been successful in comparable settings.  To identify those who cannot afford healthcare in Yirimadjo, Project Muso conducted a door-to-door household poverty and healthcare access assessment in Yirimadjo’s 5,368 households during the summer of 2008. Via principle components analysis, each household was assigned a poverty score. Those with qualifying poverty scores were identified and enrolled in the Solidarity Fund. They were provided with a registration number and a card and entered into a database at the CSCOM. The Solidarity Fund provides registered families with free care for malaria and other illnesses. Patients are also tracked in an electronic medical record-keeping system that documents all consultations, services, exams, analysis, medications, and referrals provided.

Because poverty and the ability to pay for healthcare can change over time—especially in a rapidly growing peri-urban area like Yirimadjo—registration in the Solidarity Fund is dynamic. Community Health Workers also play a role in identifying qualified families who have not yet been enrolled. An appeals process is in place for those families who fall suddenly into poverty, or whose level of poverty was not captured during the analysis. The poverty assessment will also be re-administered at regular intervals.

The establishment of a Solidarity Fund encourages community-members who would not otherwise have access to care to go to the clinic right away. That means cases of malaria and other illness are caught earlier after symptom onset. In sum, the Solidarity Fund, in conjunction with the outreach efforts of CHWs, provides rapid access to medical care for those who previously were only receiving late treatment, inappropriate treatment, or no treatment at all.

Doubling Access to Care

Removing direct and indirect cost barriers can lead to dramatic increases in health service utilization by the poor. In the 12 months before Project Muso’s Community Based Malaria Program launched in September 2008, the Yirimadjo CSCOM was overflowing with only the patients who could afford to pay for services: there were 11,056 patient visits, and during malaria season, there were not even enough beds to treat the patients who could afford to pay; patients received intravenous treatment lying on mats on the sand in a straw overflow shack. That year, before the CBMP launch, the CSCOM did not see the thousands of patients who were excluded because they could not pay for transport, services, diagnostic tests, or medications.

Through the CBMP, Project Muso has systematically removed barriers to care through Community Health Worker outreach, free care for those who cannot afford to pay, and an enhanced clinical care building to accommodate more patients.  During the first 12 months of the Community Based Malaria Program, the number of patient curative care visits at the Yirimadjo Community Health Center increased 93%, nearly doubling access to care in the area, rising to 21,288 patient visits from September 2008 to August 2009. Of these patients, 9,562 received free health care through Project Muso’s Solidarity Fund healthcare financing system. To maintain and continue to improve upon this ambitious pace of action, we will need to significantly expand our funding streams, through new commitments from existing funders and through partnerships with new funding partners.