USAID/Guinea: Local Governance Improves Health Care for Women and Children

MARCH 2, 2006

Local Governance Improves Health Care for Women and Children

A USAID-funded program helps local leaders in Kankan region launch an insurance program that makes a real difference in the provision of health care.

BATE NAFADJI - Local civic and religious leaders have joined forces to transform the government's decentralized provision of health services in this community in the Kankan region of Upper Guinea.

The result: A stronger community with better government relations, improved health services, access to vital drugs and a pioneering insurance plan that has turned El-hadj Sekou Cissé into a spirited salesman.

"Whether I'm alive or dead, I will make sure everyone buys into this insurance, because it will protect them even in hard times," the 90-year-old imam says of the program funded by USAID and implemented by PRISM (Pour Renforcer les Intervensions en Santé reproductive et MST/SIDA), a project managed by Management Sciences for Health of Boston.

El-hadj Sekou Cissé, the 90-year-old imam of Bakonko Cissela, considers insurance vital to the health of his village.

Originally aimed at providing emergency obstetrical care for child-bearing women, the community insurance program here has grown to include pre-natal care, child vaccinations, drug prescriptions, referrals for women and children, and care for the indigent. And with broad-based support from the village, prefectural and regional levels, the program is poised to expand to include all 36,000 residents in this section of Kankan.

Under the insurance program, families pay 300 Guinean francs (GF) per month (about 65 cents) for each woman and child under 5 years old. Participating family members are charged nothing when they receive services at a health center or hospital; they submit their receipts for services to an insurance committee, which then pays the health center/hospital according to a standard fee schedule.

By contrast, under the system that still prevails in much of Guinea, patients pay their health-care providers directly. Fees for services often are significantly inflated above the official rates established by Guinea's centralized health ministry, with the difference going into the pockets of local practitioners.

Before the insurance program took effect, families were frequently charged 12,000 or 15,000 GF for the birth of a child - far more than the official rate of 1,000 GF, local residents say. Under the new program, health providers in the Kankan prefecture have agreed to charge 3,000 GF for the service.

Although the Guinean government officially supports decentralization of health services, the Bate Nafadji project is one of the first to actively involve a community-based committee, consisting of representatives from each of 13 villages, in setting local health policies and prices. Exercise of local control is seen as a necessary to counteract the crisis of health-care in Guinea, where health centers lack funds to purchase drugs, workers overcharge for services and staff have no motivation to initiate improvements.

Despite the increase in the official prices, more people than ever are using health services, said Dr. Alpha Oumar Barry, health director for Kankan prefecture. "We decided to work together to set up the system and make sure that it works."

Dr. Alpha Oumar Barry, regional health director for Kankan, promotes the formation of local community health committees.

A driving force behind the community health insurance program, Dr. Barry said progress was slow under the government's decentralization strategy. For example, although the government urged communities to take more responsibility the operation of health facilities, it continued to dictate who would staff the centers, he said.

"The community was excited … but the government was still playing an important role," Dr. Barry said. "So we had to step back and look at the situation, and ask ourselves, How can we really make decentralization [of health services] happen in the Kankan region?"

The local committees are a key component of the strategy. A typical village health committee consists of a traditional birth attendant, male and female community-based distributors of family planning products, a president, vice president, a treasurer and a health center chief. Members are selected by the community using certain criteria.

With such close ties to the communities, the committee members are able to keep track of important vital statistics in the villages, such as the number of children who need vaccinations, as well as plan and manage day-to-day operations of the centers.

Those close ties extend to the village elders and, perhaps most importantly, Muslim religious leaders. In the village of Bakonko Cissela, for example, El-hadj Sekou Cissé used the "bully pulpit" of the mosque to explain the insurance plan to villagers and encourage them to sign up.

Seated on the veranda of the mosque and greeting visitors, the imam waved the insurance booklet in which the names of the women and children of his family are recorded and pronounced the community very pleased with the program.

His only question: When will the men of the village be eligible to enroll for similar insurance?

Coverage for children and men also is sought by residents in the village of Bambala, in Siguiri prefecture, where all 123 women of child-bearing age currently pay 200 GF a month for health insurance. To date, Bambala has 777,000 GF in its insurance fund, the health committee treasurer reported.

In a town meeting, one village leader said the insurance program was "a good idea, because the head of household sometimes doesn't have money" to pay for care when it is needed. The Siguiri insurance program is being implemented by ADRA (Adventist Development and Relief Agency) with funding from USAID.

Story and photos by Richard Stirba