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

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.