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TableofContents
ExecutiveSummary.............................................................................................................................1
Introduction.........................................................................................................................................5
WorkshopObjectivesandFormat........................................................................................................6
WorkshopHost.........................................................................................................................................7
WorkshopParticipants..............................................................................................................................7
WorkshopOrganizers................................................................................................................................8
WorkshopThemesandTakeaways......................................................................................................9
WorkshopEvaluations.......................................................................................................................12
ConclusionsandNextSteps...............................................................................................................13
Annexes.............................................................................................................................................14
Annex1––TheRAMEDSiteVisits............................................................................................................14
Annex2––DetailedAgenda.....................................................................................................................17
Annex3––FinalWorkshopParticipantList.............................................................................................20
Annex4––MarrakechDeclaration..........................................................................................................28
Annex3––WorkshopEvaluationSummary.............................................................................................29
š‡…—–‹˜‡—ƒ”›
Ascountriesstrivetoachieveuniversalhealthcoverage(UHC),ensuringequalaccesstoquality
health care for the poorest remains a major challenge. Many African countries are
experimentingwithdifferentapproachesandmechanismstoimproveaccesstohealthcarefor
thistargetpopulation,yetnonehasyetprovedtotallysuccessfulinimprovingaccesstohealth
careforthepoorestonanationalscale.IncoͲoperationwiththeMoroccangovernment,the
JointLearningNetworkforUniversalHealthCoverage(JLN),andUNICEF,theHarmonizationfor
Health in Africa (HHA) Financial Access to Health Services Community of Practice (FAHS CoP)
organized a fourͲday workshop, from September 24Ͳ27 in Marrakech, Morocco on improving
access to health care for the poorest. The workshop’’s focus was discussion and experience
sharinginordertodiagnose,understandandidentifystrategiestoovercomethechallengesof
covering the poorest, as well as site visits to learn from the recent scaleͲup of RAMED,
Morocco’’smedicalassistanceschemetocoverthepoor.
Over90participantsfromBenin,Coted’’Ivoire,Ethiopia,Ghana,Kenya,Mali,Morocco,Nigeria,
Rwanda and Senegal came together with CoP members, experts from Cambodia, Vietnam,
India, and international organizations. Participants included a mix of technical experts, senior
level policy makers, and parliamentarians who engaged in dynamic dialogue and exchange,
interactingfreelyandopenlywitheachotheroverthefourdaysoftheworkshop,andworking
insmallercollaborativegroupstodevelopconcretecountryactionplans.Morocco’’sMinisterof
Healthpresidedovertheopeningceremony,andpresscoverageoftheeventwassignificant.
TheworkshopagendaincludedframingandcomparativepresentationsonDay1,sitevisitsto
RAMED facilities on Day 2, analysis of challenges faced on reaching the poor on Day 3, and
political views on equity in UHC, sustainability issues, and sharing of country action plans on
Day4.Highlightsoftheworkshop’’smethodologicalapproachesincluded:
ƒ
ƒ
ƒ
ƒ
Plenarysessionswerehighlyinteractive.
Countryworkgroupsessionsprovidedanopportunityforcountriestoconveneinsmall
groupstoholdindepthdiscussionsandcollaborativelydevelopcountryactionplans.
The workshop agenda was flexible and allowed for adjustments that gave countries
moretimeforgroupworksessions.
ThesitevisitstoobserveimplementationofRAMEDencouragedworkshopparticipants
toengagedirectlywithpractitioners,andprogramadministrators,aswellastoanalyze
thestrengthsandweaknessesofaconcreteexampleofaprogramtoreachthepoorest,
andtousethislearningtobothprovidefeedbacktoMoroccoandtoinformthedesign
andimplementationoftheirowncountry’’sprogramtoreachthepoorest.
1|P a g e The workshop confirmed that much remains to be learned and documented about how to
effectively target and cover the poorest within a context of UHC. Some of the key learnings
fromthe4daysofvibrantexchangeincludethefollowingpoints.
ƒ
Defining and identifying the target population remains a major problem, and social
protectionprogramsbetterunderstandwhothepoorestare.Countriesneedtomove
towards uniform criteria and intersectoral approaches to target the poor, and better
classifypoverty(temporary/seasonalvspermanent).Participantsnotedthathealthcare
needs to be integrated into the wider scope of social protection programs and other
initiatives to reach the poor, and that poverty targeting mechanisms should be
harmonized. Participants also called for the need to consider broader social and
economicfactorsresultinginpoverty.
ƒ
There is broad consensus that strong political will and commitment are needed to
carry programs for the poorest forward; specifically to mobilize resources, identify
challenges and adapt to them, and ensure a continuous equity focus. However,
political will alone is not sufficient. Elections and social movements such as the Arab
Springcanpropelpoliciestocoverthepoorestforward,aswasthecasewiththerapid
scaleͲupoftheRAMEDinMorocco.Theformulationoftheseprogramsmust,however,
be the result of a comprehensive analysis of the context to understand all the
contributingfactorsthatrestrictaccesstohealthservices,andtoidentifyareaswhere
bottlenecksmayoccurinprovision,demand,andqualityofservicesandinterventions.
Programbeneficiariesandcivilsocietyorganizationsmusthaveaclearrolethroughout
theprocess.
ƒ
Financial sustainability is a serious concern. Financial sustainability of programs to
coverthepoorestremainsamajorchallenge,andalthoughthereisconsensusthatuser
fees must be removed, most countries have insufficient resources to finance such
programs over time. Key principles thus include putting in place progressive and
innovativewaysofraisingsufficientrevenues,establishinglargeriskandresourcepools
and avoiding fragmentation, improving efficiencies and equity of resource allocation,
andintegratingthesereformsintoacomprehensivehealthfinancingstrategy.It’’slikely,
however,thatlowerincomecountriesmayneedsignificantexternalassistanceforthe
mediumtermtoextendcoveragetothepoorest.
Active vs passive targeting of the poorest? Both are necessary. Most participants
agreed that some combination of active targeting (identifying the beneficiary before
he/she falls ill) and passive targeting (identifying the person once they are sick and in
contact with the health system) is necessary to cover the poorest. However, ensuring
thatthiscoverageofthepoorestisactuallyeffective––thatbeneficiariesactuallyusethe
services they need –– is not monitored in most cases, and needs to be. There are also
tradeͲoffs and choices that must be made to effectively target eligible populations,
ƒ
2|P a g e especiallyinruralareaswherepovertytendstobemoregeneralized.Severalparticipant
countries use communityͲbased processes and local commissions to identify and
determine eligibility of the poor, which may reduce potential errors of exclusion or
inclusion through their geographic proximity to and familiarity with communities,
inclusive processes, and accountability. In some countries, however, the familiarity of
local authorities with the population has resulted in unfair privileges for some
community members over others (leakage). Passive targeting relies on effective
communication, and yet participants highlighted the general lack of awareness and
adequate information about programs targeting the poorest especially among
beneficiaries, but also with communities, healthcare workers, social workers, health
serviceprovidersandlocalgovernments.
ƒ Strongmonitoringandevaluationsystemsareneededtoevaluatehowwellprograms
aredoing.Itisessentialtoputinplaceasystemwithclearindicatorsandreliabledata
sources to monitor progress, manage problems, and evaluate performance. The
frequent absence of reliable, systematically collected data at the community level
makes evaluating the effectiveness of mechanisms to reach the poorest difficult, as
evidencedbyMali’’sstruggletomeasuretheimpactofitsRAMED.Ghanatheoretically
coversthepoorestthroughtheNationalHealthInsuranceScheme(exemptions),butitis
having to reͲthink its data collection strategy, which currently does not allow specific
identification or tracking of this group. Participants also called for more inclusion of
beneficiary voices in monitoring programs to reach the poorest. In Cambodia,
managementoftheHealthEquityFund(HEF)isentrustedtoanindependentthirdparty
(usuallyanNGO).
ƒ One goal, multiple pathways Ͳ there is no one solution to reaching the poorest and
country contexts are important. While there exists a wide range of mechanisms and
institutionaldesignsusedtoincreasecoverageofthepoorest,theconsensusisthatthe
time has come for action everywhere. A longͲterm vision is essential, yet countries
havingmadesignificantprogressshowthatthepathtakenwilllikelybetheoutcomeof
politicalcontestationandinclusivepolicydialogues.Becausetheprocessisincremental,
flexibility and a strong monitoring and evaluation system are key to chart progress,
makeadjustments,andensurethatpublicresourcesarebeingtargetedtowardsmore
equity. The participation and empowerment of the target population can help build a
constituencyandcriticalmasstoapplyconsistentpressureforcontinuedpublicsupport
totheprogramovertime.
Theworkshopevaluationshowedaveryhighlevelofappreciationfortheworkshopformatand
content(sitevisitsuseful,exchangeswithpeersstimulating,majorityplannedtofollowͲupwith
otherparticipants).Participantswerelesscertainthattheactionplansdevelopedwerelikelyto
3|P a g e beimplemented,pointingtotheimportanceofensuringcontinuityandmobilizingsupportfor
countryͲlevelworkshopfollowͲup.
Manycountrieshavealreadybeguntotranslatetheirplanstoaction,withthedelegationfrom
Ghanareportingwithindaysoftheworkshopthattheyhadintroducedanamendmenttothe
Ghana National Health Insurance Bill mandating the National Health Insurance Authority to
annuallyreportonequityofaccesswithinGhana’’sNationalHealthInsuranceScheme.Nigeria
expressedaninterestinlearningmoreabouttheCambodiaHealthEquityFundastheyworkto
set up their Vulnerable Groups Fund, Kenya is interested in learning more about Ghana’’s
planned study to determine whether the National Hospital Insurance Scheme’’s targeting
mechanisms are effective in identifying and registering the poor, and Mali plans to make a
studytourtoGhana.
In the coming weeks and months, the FAHS CoP, in collaboration with the JLN and other
partners,willcontinuetominetheexchangesandlearningfromtheMarrakechworkshoptobe
shared in editorials, blogs and onͲline discussions. The baseline information gathered from
participatingcountrieswillalsobefurthersynthesizedandpublishedasacomparativearticle
onthestatusofequityinUHC.Wewillworkwithparticipantcountriestofurtherdocumentthe
stagestowardcoveringthepoorestontheirrespectivepathtoUHC;andtracktheirprogress
against the action plans developed in Marrakech. Where possible, the CoP will work to
consolidateexistingtoolsbeingusedtoimplementprogramstoreachthepoorest(notablyfor
identification) and make them available through onͲline platforms. One or more inͲdepth
discussions on key challenges will be held as a webinar, and inͲdepth interviews with
participantsfromMarrakechwillbeconductedtodocumentprogressmade.
In response to Morocco’’s expressed interest in further documenting, monitoring, and
evaluatingtheRAMEDexperience,theInstituteofTropicalMedicine––Antwerphasproposeda
set of potential research activities to the Ministry of Health. The CoP and its partners stand
readytoaccompanythegovernmentinMoroccointheseandotheractivities,andwillcontinue
toshareevidenceandexperienceontheevolutionoftheRAMEDthroughCoPplatforms.
Countriesrecognizethatthereisnoonesolutionforimprovingaccesstohealthservicesforthe
poorest. They are eager to learn from, and benefit greatly from opportunities to share and
exchange experiences with peers facing similar challenges. Plans to learn further from each
otherwerehatchedinMarrakech.Ascountriesseektogathertheevidenceonhowtobetter
cover the poorest and most vulnerable in their steps toward universal health coverage, the
FAHS CoP will continue to provide a dynamic forum for dialogue, discussion, and practical,
handsͲonlearningexperiencestohelpthemreachtheirgoals.
4|P a g e –”‘†—…–‹‘
Ascountriesstrivetoachieveuniversalhealthcoverage(UHC),reduceoutofpocketpayments
andprovidegreaterfinancialprotectionforallcitizens,ensuringequalaccesstoqualityhealth
care for the poorest remains a major challenge. Despite noble intentions, all too often
programs to reach the poorest do not realize their objectives: access to health care for the
poorestremainsminimalandallocatedresourcesarefrequentlyabsorbedbyotherpopulation
categories.
Many African countries are experimenting with different approaches and mechanisms to
improve access to health care for this target population: equity funds, subsidies for health
insurance premiums, health care vouchers and even cash transfers. However, none of these
mechanismshasyetprovedtotallysuccessfulinimprovingaccesstohealthcareforthepoorest
onanationalscale,highlightingamajorchallengetoreachinguniversalhealthcarecoverage.
Although there is no one size fits all approach to reaching the poorest, countries face similar
challenges in identifying and defining the poor, sustaining political commitment, mobilizing
resources, creating awareness and monitoring the progress and impact of their programs to
reach the poor, among others. Shared learning approaches can play an important role in
promoting dialogue and exchange among countries grappling with these complex issues,
allowing them to critically reflect on progress, jointly problem solve and draw on context
specificevidencefromothercountries,toarriveatsolutionsthatmeettheirneeds.
IncoͲoperationwiththeMoroccangovernmentandtheJointLearningNetworkforUniversal
HealthCoverage(JLN),theHealthforHarmonizationinAfrica(HHA)FinancialAccesstoHealth
Services Community of Practice (FAHS CoP) organized a four day workshop, from September
24Ͳ27inMarrakech,Moroccoonthetopicofimprovingaccesstohealthcareforthepoorest.
The workshop’’s topic and focus on promoting discussion and experienceͲsharing in order to
diagnose, understand and identify strategies to overcome the challenges of covering the
poorest, were identified as priorities by members of the FAHS CoP, JLN countries and
supporting partners. Embedding site visits in the workshop program to both observe the
practical implementation issues of the RAMED (Régime d’’Assistance Médicale), Morocco’’s
medicalassistanceforthepoor,andtoshareobservationsandfeedbackonscaleͲupofRAMED,
wasalsoanimportantfeatureoftheworkshop.Morocco’’sMinisterofHealthpresidedoverthe
opening ceremony, and press coverage of the event was significant. Workshop preparations
included a planning visit to Morocco (June 2012), the convening of an organizing committee
that met virtually biͲmonthly, and background research and country interviews to compile
““countrysheets””onparticipatingcountries’’programstocoverthepoorest.
Over90participantsfromBenin,Coted’’Ivoire,Ethiopia,Ghana,Kenya,Mali,Morocco,Nigeria,
Rwanda and Senegal came together over the four days to engage in interactive peerͲtoͲpeer
exchange and learning on the topic of expanding health coverage to the poorest. Country
5|P a g e delegations and CoP members were joined by experts from Cambodia, Vietnam, India, and
international organizations. The participants included a mix of technical experts, senior level
policy makers, and parliamentarians who engaged in dynamic dialogue and exchange,
interactingfreelyandopenlywitheachotheroverthefourdaysoftheworkshop,andworking
todevelopconcretecountryactionplans.AfullparticipantlistisincludedinAnnex3.
Thisdocumentsummarizestheproceedingsfromtheworkshopreportandreflectskeythemes
thatemergedfromdiscussions.Additionalinformationabouttheworkshop,includingsession
presentations can be found on the Health for Harmonization in Africa website:
http://www.hhaͲonline.org/hso/marrakesh.
‘”•Š‘’„Œ‡…–‹˜‡•ƒ†‘”ƒ–
ThemainobjectivesoftheSeptember24Ͳ27,2012workshopon““EquityinUniversalCoverage:
HowtoReachthePoorest””wereto:
ƒ
ƒ
ƒ
ƒ
ƒ
Identifyanddocumentefficientstrategiestocoverthepoorest(fromAfricancountries
andothercountrieswhererelevant);
Diagnose how and why mechanisms intending to cover the poorest have been less
successfulthandesiredandseeksolutionstoovercomeweaknesses;
Identify gaps in knowledge concerning coverage of the poorest and define research
priorities;
Linkstrategiesforcoverageofthepoorestwithotherfinancialstrategiesforuniversal
healthcarecoverage;
Support countries in drawing up action plans to improve their policies on access to
healthcareforthepoorest.
Theworkshopwasdesignedtofacilitatepeertopeerlearningandexchangebetweencountries
andamongvariousactorsfromeachcountry.Theagendafortheworkshopfollowedthehigh
leveloutlinebelow:overviewandframingpresentationsonDay1,sitevisitstoRAMEDfacilities
on Day 2, analysis of challenges faced in reaching the poor on Day 3, and political views on
equityinUHC,sustainabilityissues,andsharingofcountryactionplansonDay4. Adetailed
workshopagendawithsessiontitlesandpresenterinformationisincludedinAnnex2.
Day1
Day2
Day3
Day4
Workshopframingandsharingofexperiencesamongparticipatingcountrieson
differentmechanismstocoverthepoorestanddiscussionofhealthequity
SitevisitstoobserveimplementationofRAMED
Analysis of the challenges faced in covering the poorest (analysis at countryͲ
levelandcomparativeanalysis),sharingoffeedbackonRAMED
PoliticalviewsonequityinUHC,sustainabilityissues,sharingofcountryaction
plans,andworkshopwrapͲup
6|P a g e Highlightsoftheworkshop’’smethodologicalapproachincluded:
ƒ
ƒ
ƒ
ƒ
Plenarysessionswerehighlyinteractive.
Countryworkgroupsessionsprovidedanopportunityforcountriestoconveneinsmall
groupstoholdindepthdiscussionsandcollaborativelydevelopcountryactionplans.
The workshop agenda was flexible and allowed for adjustments that gave countries
moretimeforgroupworksessions.
ThesitevisitstoobserveimplementationofRAMEDencouragedworkshopparticipants
toengagedirectlywithpractitioners,andprogramadministrators,aswellastoanalyse
thestrengthsandweaknessesofaconcreteexampleofaprogramtoreachthepoorest,
andtousethislearningtobothprovidefeedbacktoMoroccoandtoinformthedesign
andimplementationoftheirowncountry’’sprogramtoreachthepoorest.(SeeAnnex1)
WorkshopHost:MinistryofHealth,Morocco
SincethefirstFAHSCoPworkshopheldinNovember2011inBamako,Malionmaternalhealth
fee exemptions, Morocco has played a dynamic leadership role in the CoP. Given that
expanding access to healthcare for the poorest was a top priority for the government of
Morocco,CoPmembersfromthehighestlevelsoftheMoroccanMinistryofHealthpresentat
theBamakoworkshopsuggestedhostingthenextannualCoPevent.AsRAMEDwaspreparing
to expand from a pilot phase to a national level program, Morocco proved to be a unique
concretelearningopportunity,aswellasanenthusiastic,engagedhostcountryandworkshop
coͲorganizer.
Aware of the many challenges of scalingͲup such a program Ͳ from technical implementation
issuesassociatedwithidentifyingandenrollingthepoor,tofinancialsustainabilityconcerns,to
sustaining political will and government commitment Ͳ and recognizing that other countries
facesimilarchallenges,MoroccowaskeentohostaCoPworkshopthatwouldbringtechnical
expertsanddecisionmakerstogethertoreviewtheevidencebaseonmechanismstoreachthe
poorestandtosharecountryexperiences,andtoprovidefeedbackandinsightsontheRAMED
withinacontextofUHC.Morocco’’spilotexperienceimplementingRAMEDandrecentscaleͲup
of the program offered an opportunity for workshop participants to see and discuss the
practical implementation issues of programs designed to cover the poorest. Marrakech was
selected as the venue for the workshop because of its proximity to RAMED implementation
sites.
WorkshopParticipants
The workshop convened country delegations and CoP members from ten African countries
(Anglophone and Francophone): Benin, Côte d’’Ivoire, Ghana, Kenya, Mali, Morocco, Nigeria,
Rwanda, Senegal and Ethiopia. Delegations included high level decision makers, technical
7|P a g e expertsinvolvedinimplementingprogramsandpoliciestocoverthepoorest,practitionerswith
direct operational experiencesand parliamentarians. Somewhat lacking from delegations was
representation from civil society and from outside the health sector. Workshop participants
also included experts from ““resource countries1”” Cambodia, India, Vietnam and several
internationalorganizations.AfullparticipantlistisincludedinAnnex3.
Participant countries were selected based on their engagement in universal health coverage
reformsandcurrentimplementationofstrategiestoreachthepoorest,aswellasthepresence
ofapartnerwillingtofundtheirparticipation.
WorkshopOrganizers
FAHSCoP2
The Financial Access to Health Services Community of Practice (FAHS CoP) supports the
development and implementation of initiatives and policies to improve financial access to
healthcareinAfricaandtopromoteconstructivesharingofexperienceandexpertiseamong
countries. By mobilizing experts working on policies and mechanisms to improve financial
accessacrossthecontinent––throughvirtualexchangesandduringworkshops––theFAHSCoP
actsasaforumtogatherandshareknowledgeamongitsmembers.TheCoPalsoservesasa
platformtocoordinateinitiativesledbydifferentactorsandsupportingagencies.
JLN3
TheJointLearningNetworkforUniversalHealthCoverage(JLN)isaplatformforknowledge
andsouthͲsouthexchangesforcountriesimplementinghealthcarefinancingreforms.Theaim
istoimprovefinancialprotectionandaccesstohealthcareserviceswithinauniversalhealth
carecoverageframework.
Since its creation in 2010, the JLN has ten country members: Ghana, India, Indonesia, Kenya,
Malaysia, Mali, Nigeria, the Philippines, Thailand and Vietnam. The JLN is built around four
technical tracks, defined by members of the network: provider payment mechanisms,
informationsystems,expandingcoverage.Itisthroughits““ExpandingCoverage(EC)””trackthat
the JLN supported theCoP workshop in Morocco. The EC track facilitates knowledge transfer
and exchange among member and resource countries across the benefit (essential and costͲ
effectiveinterventions)andpopulation(informalsector,disadvantagedgroups)dimensions.
TheGovernmentofMorocco
The topic of medical coverage for the poor is a major focus for the Governmentof Morocco
sinceitconcernssome8.5millioninhabitants,inotherwords,around28%ofthepopulation.
InNovember2008,Moroccobeganpilotingamedicalassistancescheme(RAMED)intheTadla
1
Withlonger,yetstillfairlyrecentexperiencethanparticipantcountriesandsignificantprogressincoveringthepoorest,these
countrieswereinvitedasresourcecountriestosharelessonsandadvice.
2
http://www.hhaͲonline.org/hso/financing/group/accesstoservices
3
http://www.jointlearningnetwork.org
8|P a g e Azilalregion(targetpopulationof420,000inhabitantsoutofatotal1.5million).Assessmentof
the pilot phase in 2010 led to recommendations about scaling up RAMED, which, on orders
from the King of Morocco, was launched on a national scale in 2012, one year prior to its
plannedextension.
TheMinistryofHealthhasputanationalobservatory,alongwithregionaloffices,inplaceto
document and monitor the scaleͲup process (and ultimately, to measure equity in access to
healthservices).Theobservatory,afeatureofthesitevisits,providesongoingsupporttothe
scaleͲupofRAMEDandistaskedwithreportingonissuesthatmayarise.
UNICEF/WestandCentralAfricaRegionalOffice(WCARO)
In2012,UNICEFadoptedastrategicframeworkforsocialprotection4,aimingtoextendhealth
carecoveragesupportedbysustainableandequitablefinancialsystems.Since2010,UNICEFis
also at the forefront in terms of support to the HHA strategy to strengthen Communities of
Practice.
‘”•Š‘’Š‡‡•ƒ†ƒ‡ƒ™ƒ›•
The workshop confirmed that much remains to be learned and documented about how to
effectively target and cover the poorest within a context of UHC. Some of the key learnings
fromthe4daysofvibrantexchangeincludethefollowingpoints.
ƒ
Defining and identifying the target population remains a major problem, and social
protectionprogramsbetterunderstandwhothepoorestare.Countriesneedtomove
towards uniform criteria and intersectoral approaches to target the poor, and better
classify poverty (temporary/seasonal ––vsͲ permanent). Participants noted that
healthcare needs to be integrated into the wider scope of social protection programs
andotherinitiativestoreachthepoor,andthatpovertytargetingmechanismsshould
beharmonized.InGhanatheNationalHealthInsuranceAuthority(NHIA)haspartnered
withasocialprotectionprogramtodevelopanationaltargetingmechanism.Cambodia
recognizes the need to harmonize and integrate the Health Equity Fund (HEF) into a
wider social health protection framework. Participants called for the need to consider
broadersocialandeconomicfactorsresultinginpoverty.
ƒ
There is broad consensus that strong political will and commitment are needed to
carry programs for the poorest forward; specifically to mobilize resources, identify
challenges and adapt to them, and ensure a continuous equity focus. However,
political will alone is not sufficient. Elections and social movements such as the Arab
Springcanpropelpoliciestocoverthepoorestforward,aswasthecasewiththerapid
4
http://www.unicef.org/socialprotection/framework/index_61841.html
9|P a g e scaleͲupofRAMEDinMorocco.Theformulationoftheseprogramsmust,however,be
theresultofacomprehensiveanalysisofthecontexttounderstandallthecontributing
factors that restrict access to health services, and to identify areas where bottlenecks
may occur in provision, demand, and quality of services and interventions. Program
beneficiaries and civil society organizations must have a clear role throughout the
process.InIndia,despitethefactthathealthcareisahighlypoliticizedissue,effortsto
coordinate policy discussions with operational aspects of programs to reach the poor
havenotbeensuccessful.Severalcountriesnotedhowtensionsbetweenfederaland
state structures hindered progress in expanding coverage. In Senegal and in Mali,
despite strong support from the Ministry of Health, the Equity Fund and RAMED are
strugglingtoattractlocalgovernmentinterestandfunding.InNigeria,whereeachstate
decidesitsownhealthpolicy,progressinscalingͲupprogramstoreachthepooresthas
beenslowduetothelackofstateͲlevelbuyͲinandcommitment.
ƒ
Financial sustainability is a serious concern. Financial sustainability of programs to
coverthepoorestremainsamajorchallenge,andalthoughthereisconsensusthatuser
fees must be removed, most countries have insufficient resources to finance such
programs over time. Key principles thus include putting in place progressive and
innovativewaysofraisingsufficientrevenues,establishinglargeriskandresourcepools
and avoiding fragmentation, improving efficiencies and equity of resource allocation,
andintegratingthesereformsintoacomprehensivehealthfinancingstrategy.It’’slikely,
however,thatlowerincomecountriesmayneedsignificantexternalassistanceforthe
mediumtermtoextendcoveragetothepoorest.
ƒ
Active vs passive targeting of the poorest? Both are necessary. Most participants
agreed that some combination of active targeting (identifying the beneficiary before
he/she falls ill) and passive targeting (identifying the person once they are sick and in
contact with the health system) is necessary to cover the poorest. However, ensuring
thatthiscoverageofthepoorestisactuallyeffective––thatbeneficiariesactuallyusethe
services they need –– is not monitored in most cases, and needs to be. There are also
tradeͲoffs and choices that must be made to effectively target eligible populations,
especiallyinruralareaswherepovertytendstobemoregeneralized.Manyparticipant
countries use communityͲbased processes and local commissions to identify and
determine eligibility of the poor, which may reduce potential errors of exclusion or
inclusion through their geographic proximity to and familiarity with communities,
inclusive processes, and accountability. In some countries, however, the familiarity of
local authorities with the population has resulted in unfair privileges for some
community members over others (leakage). Passive targeting relies on effective
communication, and yet participants highlighted the general lack of awareness and
adequate information about programs targeting the poorest especially among
beneficiaries, but also with communities, healthcare workers, social workers, health
serviceprovidersandlocalgovernments.
10|P a g e Dr. Tran Van Tien (Ministry of Health, Vietnam) explained that Vietnam has adopted
nationalguidelinestoidentifythepoorin 50,000villages, basedonmeansandproxyͲ
means testing. A community targeting process that involves multiple representatives
(medical, social, head of village, civil, etc.) is used. In Ghana, the NHIS promotes
community ownership and a participatory process of identification and enrolment, in
order to strengthen transparency and accuracy. In Cambodia, households are preͲ
identified at the community level through screening and postͲidentified at health
facilities through interviews. A common constraint in these community targeting
processes is their timeͲintensive nature, which may result in temporary exclusion and
havedifficultykeepingpacewithpovertydynamics.
WhileMoroccodidemployacommunicationcampaigntolaunchtheRAMED––including
campaigns, television spots and advertisements, and pamphlets Ͳ participants noted
that RAMED primarily uses a passive identification process. There was general
agreementthatthisapproachcanfailtocapturethosewhoneedtoaccessservicesthe
most,thepoorestinhardtoreachruralareas,andthevulnerable.AsnotedbyThiMinh
Phuong Ngo (UNICEF) in her presentation, targeting that occurs when patients are ill
oftenresultsinerrorsofinclusionandexclusion.
ƒ
Strongmonitoringandevaluationsystemsareneededtoevaluatehowwellprograms
aredoing.Itisessentialtoputinplaceasystemwithclearindicatorsandreliabledata
sources to monitor progress, manage problems, and evaluate performance. The
frequent absence of reliable, systematically collected data at the community level
makes evaluating the effectiveness of mechanisms to reach the poorest difficult, as
evidencedbyMali’’sstruggletomeasuretheimpactofitsRAMED.Ghanatheoretically
coversthepoorestthroughtheNationalHealthInsuranceScheme(exemptions)butitis
having to reͲthink its data collection strategy, which currently does not allow specific
identification or tracking of this group. Participants also called for more inclusion of
beneficiary voices in monitoring programs to reach the poorest. In Cambodia,
managementoftheHealthEquityFund(HEF)isentrustedtoanindependentthirdparty
(usuallyanNGO).
ParticipantslearnedabouttheITsystemputinplaceforMorocco’’sRAMEDtofiledaily
and monthly activities, collect referral and counterͲreferral data, and monitor RAMED
casesatthehospitallevel5.
ƒ One goal, multiple pathways Ͳ there is no one solution to reaching the poorest and
countrycontextsareimportant.
5
RAMEDisoperationalatthehospitallevelashealthservicesatlowerlevelsofthehealthsystemareprovidedforfree.
11|P a g e While there exists a wide range of mechanisms and institutional designs used to
increase coverage of the poorest, there is broad consensus that now is the time for
actioneverywhere,andthatpaststrategieshavenotbeeneffective.AlongͲtermvision
isessential,yetcountrieshavingmadesignificantprogressshowthatthepathtakenwill
likely be the outcome of political contestation and inclusive policy dialogues. Because
theprocessisincremental,flexibilityandastrongmonitoringandevaluationsystemare
key to chart progress, make adjustments, and ensure that public resources are being
targeted towards more equity. The participation and empowerment of the target
populationcanhelpbuildaconstituencyandcriticalmasstoapplyconsistentpressure
forcontinuedpublicsupporttotheprogramovertime.
‘”•Š‘’˜ƒŽ—ƒ–‹‘•
During the workshop, ‘‘live’’ evaluations were undertaken in order to understand the
participants’’ views of the content and format of the workshop activities. These evaluations
weredonewiththe““TurningPoint””technology,whichallowspollstobecarriedoutwiththe
useofMSPowerPointand““clickers””distributedtorespondents.
OnͲtheͲspotevaluationswereconductedduringthreesessionsofquestions;theresponserate
was 80% on average for each question. Questions focused on the usefulness of the different
sessions,theworkinggroupsonactionplans,andthegeneralqualityoftheworkshop.Thefull
resultsoftheevaluationscanbefoundinAnnex5,butselectedresultsarepresentedbelow.
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
100%oftherespondentsfoundthefieldvisitusefulorveryuseful.
90%oftherespondentsagreedorstronglyagreedfoundthesmallgroupdiscussionson
thefieldvisitsdynamicandstimulating,and72%founditpertinentorverypertinentto
brainstormonanactionplanfortheircountry.
50%oftheconcernedrespondentsansweredthattheactionplantheyworkedonwould
verylikelyplayaroleintheircountry’’sstrategiesaftertheirreturn.33%answeredthat
itwassomewhatlikely,while17%thoughtthatitwasnotverylikelyornotlikelyatall.
95%foundthatasofday3,thecontentandthelevelofexchangehadbeenthoughtͲ
provokingforthem.
95% agreed or strongly agreed with the statement that, overall, the process of
describingtheirowncountrychallengescausedthemtoreflectandthinkconstructively
abouttheircountry’’ssituation.
98%agreedorstronglyagreedwiththestatementthattheworkshophadbeenvaluable
forthemoverall.
91%agreedorstronglyagreedwiththestatementthattheyexpectedtofollowupwith
otherparticipantsfromtheworkshopafterwards.
12|P a g e ‘…Ž—•‹‘•ƒ†‡š––‡’•
Manycountrieshavealreadybeguntotranslatetheirplanstoaction,withthedelegationfrom
Ghanareportingwithindaysoftheworkshop,thattheyhadintroducedanamendmenttothe
Ghana National Health Insurance Bill mandating the National Health Insurance Authority to
annuallyreportonequityofaccesswithinGhana’’sNationalHealthInsuranceScheme.Rather
thanissuingaformaltraditionalworkshopdeclaration,participantswereinspiredbytherecent
documentary ““AhͲ les indigents”” (by Malam Saguirou) to issue the ““Marrakech Declaration,””
shared on the HHA Facebook page (www.facebook.com/hhacops), which, in the spirit of the
CoP, is an individual call to action to improve coverage of the poorest and most vulnerable
(includedasAnnex5).
In the coming weeks and months, the FAHS CoP, in collaboration with the JLN and other
partners,willcontinuetominetheexchangesandlearningfromtheMarrakechworkshoptobe
shared in editorials, blogs and onͲline discussions. The baseline information gathered from
participatingcountrieswillalsobefurthersynthesizedandpublishedasacomparativearticle
onthestatusofequityinUHC.Wewillworkwithparticipantcountriestofurtherdocumentthe
stagestowardcoveringthepoorestonthepaththeUHC;andtracktheirprogressagainstthe
actionplansdevelopedinMarrakech.Wherepossible,theCoPwillworktoconsolidateexisting
toolsbeingusedtoimplementprogramstoreachthepoorest(notablyforidentification)and
make them available through onͲline platforms. One or more inͲdepth discussions on key
challengeswillbeheldasawebinar.
In response to Morocco’’s expressed interest in further documenting, monitoring, and
evaluatingtheRAMEDexperience,theInstituteofTropicalMedicine––Antwerphasproposeda
set of potential research activities to the Ministry of Health. The CoP and its partners stand
readytoaccompanythegovernmentinMoroccointheseandotheractivities,andwillcontinue
toshareevidenceandexperienceontheevolutionoftheRAMEDthroughCoPplatforms.
Countriesrecognizethatthereisnoonesolutionforimprovingaccesstohealthservicesforthe
poorest. They are eager to learn from, and benefit greatly from opportunities to share and
exchange experiences with peers facing similar challenges. Plans to learn further from each
other were hatched in Marrakech, with Ghana planning to bring a group back to Morocco,
NigeriaexpressinganinterestinlearningmoreabouttheCambodiaHealthEquityFundasthey
worktosetuptheirVulnerableGroupsFund,Kenyaidentifyinginterestinlearningmoreabout
Ghana’’s planned study to determine whether the National Hospital Insurance Scheme’’s
targetingmechanismsareeffectiveinidentifyingandregisteringthepoor,andMalihopingto
makeastudytourtoGhana.Ascountriesseektogathertheevidenceonhowtobettercover
thepoorestandmostvulnerableintheirstepstowarduniversalhealthcoverage,theFAHSCoP
will continue to provide a dynamic forum for dialogue, discussion, and practical, handsͲ on
learningexperiencestohelpthemreachtheirgoals.
13|P a g e ‡š‡•
Annex1TheRAMED––Sitevisits
Fieldvisits
Onthesecondday,fieldvisitswereconductedinthecommunesofMarrakesh,Essaouira(170
kmfromMarrakesh)andElKalaa(80kmfromMarrakesh).Participantsvisitedthecommunity
building,whereapplicationsandregistrationsareconducted.Theprocesswaspresentedtous
by members of the permanent commission: the Caïd (district commissioner) and the Khalifa
(deputyheadofdistrict)––bothcivilservants,appointedbyHisMajestytheKingofMorocco.
InEssaouira,450applicationshavebeenprocessed,127poorandaround100vulnerable.Five
to six vulnerable beneficiaries were not able to pay for the card. These cases are being
reviewed.IntheLagunehealthcentre,44patientsareRAMEDbeneficiaries.
14|P a g e Applica
ationpro
ocedure
1. Applicationsaresubmittedto
otheadministrativeoff ice.
2. Thelo
ocalcommisssionreview
wsitandcheccksitsautheenticity.
3. TheC
Caïdsignsan
nddatesthe
eapplication
nanddelive rsareceipt totheappliicant.Thisserves
asan
ninterimdoccumententittlingtheapp
plicanttofreeeemergenccyhealthcareforaperiodof
three
emonths(orruntiltheoffficialRAMED
Dcardisdellivered).
4. Inparallel,afield
denquiryis conducted tofindout thelivingco
onditionsofftheapplicaant.A
repre
esentativeoffthecommiissionwillco
overonestr eet.Allappllicantsarereviewedino
order
toen
nsureagainstterrorsofin
nclusionore
exclusion.
5. Follow
wing 40 pro
ocessed applications, th
he commissi on represen
ntatives crosss check all their
inform
mationfore
eachapplicattion,toensu
uretheauth enticityand
deligibilityofftheapplicaant.
6. Applicationsaresenttothep
prefecturefo
orelectroniccregistrationanddecisiononeligibility.
7. The decision
d
is then sent baack. The responsecan bbe ‘‘eligible’’ (poor or vu
ulnerable) orr ‘‘not
eligib
ble’’.Ifanap
pplicationis turneddow
wn,theappliicantcanap
ppealforassecondrevieew.A
further investigaation will be
b conductted, to wh ich the ap
pplicant, ph
hysician or local
comm
missionmem
mbermayad
ddanyrelevaantinformattionorjustiffications.
8. Ifthe
eapplicantisseligible,the
eyarecalled
dtotheadm
ministrationo
officetopickuptheircaard.If
their statusis‘‘po
oor’’,thecardisfreeoffcharge.Ifttheirstatus is‘‘vulnerab
ble’’,a120DH
Hfee
per person
p
(up to
t 600DH maximum
m
pe
er householdd beyond five memberrs) is requireed to
receivvethebene
eficiarycard.Vulnerable
ebeneficiari eshavelefttwithouttheircards,dueto
lacko
offunds.The
eycanappeaaltobeclasssifiedaspooor.
Figure1.A
Applicationp
procedureforrRAMED
Step1:R
RAMED
applicationform
submissiion
Step6:Delliveryof
cardsbyLo
ocal
Authority
155days
Step22:Reviewof
appliccationby
LocalCommission
n
30
0days
30days
Step5:ANAM
registersRA
AMED
cards
Step33:Permanen
nt
LocalC
Commission
n
enquiry
Rejecttion/Appeaal
(Walii,Governor)
Step4:Re
egional
Permanen
nt
Commission:finalist
660days
15|P a g e Feedba
ackfromp
participa
antsando
observatio
onsonRA
AMED
Strengths
Weakne
esses
Identificationand
dRegistratio
on
ƒ Permanentl
P
ocalcommisssiontoproccessapplicattionsandmonitor
cant’’seligibility
ƒ Doubleenqu
D
uiryonapplic
ƒ Illiteracyhassnotlimitedhighapplica
ationnumbeers
ƒ Adequateto
A
olstomanageapplicatio
ons
ƒ Possibilityto
P
oappealifap
pplicationisrefused
Coverrage/Serviccesprovided
d
ƒ Automatic
A
delivery
d
of application
n receipt, applicants can beneffit from
immediatee
emergencycare
ƒ Nopayment
N
atfirstpoin
ntofcare,athealthcenttres
ƒ Samelevelo
S
ofcoveragefforRAMEDaandnonRAM
MEDbeneficciaries
ƒ Coverageof
C
transportin
ncaseofeme
ergency
ƒ Expensive
E
treatments are available to RAM ED beneficiaries (e.g. corneal
transplant,d
t
dialysis)
ƒ Wellorganis
W
edhealthsttructures
ƒ Goodreferra
G
alsystem
Weakn
nesses
Identifficationand
dRegistratio
on
ƒ SelfͲdeclaration,passiverecruitmentt,application
nfollowingillness
ƒ Risk of fraud
d, need for photograph
hs of all ho usehold beneficiaries, not only
motherandf
m
father
ƒ Waitingtime
W
RAMEDcardfollowingappplication
toreceiveR
ƒ High
H
adminisstrative costts to proce
ess applicatiions, conduct double eenquiries
(ccentralandlocal)
MonittoringandEvvaluation
ƒ La
ackoffeedb
backonimpaactofRAMEDonseconddaryhealthccare
ƒ Drugshortag
D
es,leadingttoOOPpaym
ments
ƒ Frequentrenewalofstatusandcardss(2to3yea rs)
ƒ La
ackofrealm
monitoringandevaluatio
onofthesysstemintheo
observatory
16|P a g e Annex2ǦDetailedAgenda
Sunday23 September
Arrivals,transporttoMarrakesh
5:00––8:00PM
Registrationofparticipants(HotelKenziFarah)
DAY1––Monday24thSeptember
8:00––9:00AM
Participantregistrationandwelcome
9:00––10:00AM
Opening
Presentationofparticipants
WelcomefromtheFAHSCoP
WelcomefromtheMoroccanMoH
Presentationoftheworkshopobjectives
Presentationoftheprogram
Informationonlogistics,notablyregardingthefieldvisit
(FAHSCoPfacilitatingteam)
10:00––10:40AM
Frameworkpresentation:Universalcoverageandequity
x Universalhealthcarecoverage
x Fragmentationofpresenthealthcoverageindevelopingcountries
(andparticularlyinAfrica)
x Challengesandstakesofhealthcoverageforthe““poorest””
Presenter:FahdiDkhimi,ITMͲAntwerp
10:40––11:10AM
Coffeebreak
11:10AM––12:30PM Groupdiscussionsbetweenpeercountries
Preparatoryworkfordevelopinganactionplan
x Presentation/Analysisoftheprincipalinequalityindicators(if
available)
x Country’’spresentsituationwithrespecttouniversalcoverage
objectives(cube––universalcoverage)
x Principalstrategyorstrategiesimplementedinordertocoverthe
poorest
x Principallessons(2)concerningcoverageofthepoorest(strengths,
weaknessesofthesestrategies)
12:30––1:15PM
OverviewofmechanismsimplementedinAfrica:summaryof
experiencesfromparticipatingcountries(resultsfromquestionnaire)
Presentationandplenarydiscussion
Presenter:AbebaTaddese,ResultsforDevelopment/JLN
1:15––2:30PM
Lunchbreak
2:30––3:45
Theevidencebaseonmechanismstoextendhealthcovertothe
5minpercountry,
poorestindevelopingcountries
20mindiscussion
Presenter:ValéryRidde,MontrealUniversity
Presentationofcasestudies(HEFCambodia,RSBYIndia,Vietnam,
Ghana)
Presentationsandpaneldiscussions
Presenters:Por,Seshadri,Tien,Gingong
3:45––4:15PM
Coffeebreak
4:15––5:30PM
TheRAMEDinMorocco:experienceandlessonslearntfromthepilot
rd
17|P a g e 5:30––6:00PM
6:00––6:15PM
6:15––6:35PM
6:35––6:55PM
6:55––7:15PM
7:15––7:30PM
7:30PM
7:00/7:30/8:30AM
4:30––5:00PM
phase
Presentation(RegionalHealthDirectorofTadlaAzilal),followedby
panelmoderateddiscussions(multipleactorsofTadlaAzilalpilot
region)
Moderator:Dr.Ennaciri,MoroccanMinistryofHealth
Organizationandplanningoffieldvisits(Day2)
Officialopeningoftheworkshop––Welcomeofparticipants
Summary/conclusionsofthefirstday:
Differentpoliticaloptionstoexpanduniversalhealthcovertothe
poorest
x Reminderonnotionofequityinhealth,healthcoverageandhealth
inequalities+Stakesofuniversalhealthcoverage
x Typologyofdifferentmechanismsimplementedtoovercome
inequalitiesandimproveaccessforthepoorest
x Strengthsandweaknessesofeachmechanism
x Principallessonsfromcasestudies
Presenters:Makinen(ResultsforDevelopment)
UniversalHealthCoverageStrategyinMoroccoandstakesofnational
expansionforRAMEDandotherinterventions
AddressoftheMinisterofHealthofMorocco
AddressfromtheEUambassadortoMorocco
ConclusionsandclosingwordsfromtheCoPandtheMinisterofHealth
ofMorocco
CocktaildinnerofferedbytheFAHSCoP
DAY2––Tuesday25thSeptember
DepartureforfieldvisitsintheTensiftAlhaouzregionofMarrakesh
x Visitsofhealthstructures(communityhealthcenterswith
maternityfacilitiesandprovincehospital)intheprovincesElKalaa
andEssaouira,andtheprefectureofMarrakesh
x Visittotheregionalhospital,universityhospitalcenter,and/orthe
RAMEDregionalobservatory
x Eachgroupwillbeaccompaniedbyaresourcepersonfrom
Morocco,anexpertandaninterpreter
x Lunchbreakinthefield
Returntohotel,informalmeetingbycountry––observations,ideas,
lessonslearnt
8:30––9:15AM
9:15––10:45AM
10:45––11:15AM
Day3––Wednesday26September
HighlightsDay1et2
ObjectivesDay3
Evaluation(1stphase)
Discussionsaroundthemainfindings/observations/impressions/key
challengesonthefieldvisit.
Groupworkincountrypairs,Groupingbylanguage
Coffeebreak
18|P a g e 11:15AM––12:45PM
12:45––2:00PM
2:00––2:15PM
2:15––2:30PM
3:30––4:15PM
4:15––4:45PM
4:45––5:30PM
7:30PM
IdentifyingthepoorestͲapproachesandchallenges
InterͲsectoralpaneldiscussion
Discussioninplenary
Moderator:ThiMinhPhuongNgo/UNICEFͲWCARO
Lunchbreak
WorldTour––Assessmentofthepassports
Howtomonitorequity––methodsandcasestudyfromSenegal
(practicalapplicationtoresultbasedfinancinginterventions)
Presentationanddiscussioninplenarysession
Presenter:AlexErgo
Groupworkbydelegation
x Keylessons
x Mainchallenges
x Actionplan
CoffeeBreak
Groupwork(continued)
DepartureforGaladinner(offeredbytheMoroccanMinistryof
Health)
Day4––Thursday27September
8:30––9:15AM
RecapDay3
ObjectivesDay4
Evaluation(2ndphase)
9:15––10:15AM
RoundtablewithMembersofParliament:UHCandequityfroma
politicalperspective
Moderator:MartyMakinen,ResultsforDevelopment
10:15––10:45AM
Coffeebreak
10:45––11:45AM
Providingeffectivecoverageofthepoorest:linksbetweendifferent
mechanismstoreachthepoorestandnationalstrategiestofinance
healthcare/socialprotection/developmentandgrowth
PresentationandinterͲsectorialpaneldiscussions
Presenter/moderator:RikuElovainio,WHO
11:45AM––12:45PM Finalcountryactionplanning
Groupworkbydelegation
12:45––2:00PM
Lunchbreak
2:00––3:30PM
Expectationsreached?«Feedback»fromdifferentdelegations––
lessonslearnt,actionplans
«Talkshow»format+Evaluation3rdphase
Moderator:BrunoMeessen,IMT
3:30––4:15PM
Closingceremony
x SynthesisofthemainrecommendationfortheRAMED
implementation,researchtracksandwayforward
x ClosingspeechCoP/JLN/MOH
End
19|P a g e Annex3ǦFinalWorkshopParticipantList
COUNTRY
TITLE/ROLE
NAME
Benin
DeputySecretaryGeneraloftheMinistryofHealth
JustinAdanmavokinSossou
Benin
FocalPointforRégimed'AssuranceMaladieUniverselle(RAMU)
HuguesTchibozo
Benin
CoordinatorofPRPSS
AlphonseAkpamoli
Benin
HospitalDirectorforBassilaZone
CyrGoudalo
Benin
DirectorofAIMSParakou
IsmailouYacoubou
Ghana
Director,Adm.&GeneralCounsel,NationalHealthInsurance
Authority
NathanielOtoo
Ghana
AgDirector,Operations,NationalHealthInsuranceAuthority
AnthonyGingong
Ghana
Director,CentralRegionalHospital,CapeCoast
DanielAsare
Ghana
MemberofParliament&DeputyRankingMember,Parliamentary
CommitteeonHealth
MatthewOpokuͲPrempeh
Ghana
NHISFocalPerson,PlanningPolicyMonitoring&EvaluationDivision,
MinistryofHealth
RahiluHaruna
Ghana
Manager,DistrictMutualHealthInsuranceScheme,WestGonja
JohnKippoKara
Kenya
ChiefEconomist,MinistryofMedicalServices
ElkanaOnguti
Kenya
MalindiBranchManager,NHIF
OmarMwatabu
20|P a g e Kenya
SeniorProgrammeOfficer,NHIF
JulietMaara
Mali
MinisterofHumanitarianAction,Solidarity,andtheElderly
MamadouSidibé
Mali
NationalDirector,SocialProtectionandEconomicSolidarity
AnkoundioLucTogo
Mali
GeneralDirector,ANAM
FadimataMaiga
Mali
MemberoftheHighCouncilofLocalGovernments
MamadouTraoré
Mali
TechnicalAdvisortotheMinistryofHumanitarianAction,Solidarity,
andtheElderly
AlmouctarHaidara
Mali
ChiefofHospitalSocialServices,Mali
SeydouTraoré
Morocco
DirectorofHospitalServicesandAmbulatoryCare,MinistryofHealth
AbdelaliBelghitiAlaoui
Morocco
GeneralDirector,ANAM
ChakibTazi
Morocco
DivisionChiefforHospitalServices,MinistryofHealth
AhmedBoudak
Morocco
DirectorforRegionalHealthServicesforTadlaAzilaregion,Ministryof MalmouzNourredine
Health
Morocco
DirectorforRegionalHealthServicesforMarrakechTansiftAlHaouz,
MinistryofHealth
AchibetMustapha
Morocco
Deputy,MinistryofHealth
BrahimiMostafa
Morocco
Deputy,MinistryofHealth
FatimaMazziGouaima
Morocco
DivisionChiefforCommunication,MinistryofHealth
AbdelghaniDrhimeur
21|P a g e Morocco
MinistryofHealth
MalikaMazine
Morocco
Official,MinistryofHealth
LafkiriHatim
Morocco
ResearchDirector,MinistryofHealth
HichamMouhdi
Morocco
SecretaryGeneral,MinistryofHealth
ElOuardZakaria
Morocco
MinistryofHealth
KhoudariRachid
Morocco
Manager,MinistryofHealth
ZekkaouiMohammed
Morocco
DivisionChief,Auditing,ANAM
AbdellatifMoustatraf
Morocco
Doctor
HamouiyiMohammed
Morocco
PFEquitéetsanté,WorldHealthOrganization(WHO)
MmeJabalS.
Morocco
Programdirector,EuropeanUnion(EU)
ElFarjaniHikmat
Morocco
Representative,UnitedNationsPopulationFund(UNFPA)
LardiMohammed
Morocco
Expert,BAD
JaaforLeila
Morocco
Healthspecialist,UNICEF
AhmedLaabid
Nigeria
GeneralManager(Tech.Operations),NHIS
HopeUweja
Nigeria
DeputyGeneralManager/NHISLagosZonalCoordinator,NHIS
Victor.C.Amadi
Nigeria
FamilyHealthDept.,FedMinistryofHealth
Dr.D.B.Okara
Nigeria
HouseCommitteeonHealth
Mr.NasiruGarbaShehu
22|P a g e Nigeria
Manager,TechnicalOperationsDepartment,NHIS
Mr.AgboolaOluwasunkanmi
Senegal
Director,CabinetoftheMinistryofHealth
MameAbdoulayeGueye
Senegal
Coordinator,SupportCellforUniversalHealthCoverage
OusseynouDiop
Senegal
Doctor,DistrictchiefofBambey
JacquesDiaméNdour
Senegal
Sociologist,CAFSP
RokhayaBadianeMBAYE
Senegal
Deputy,PresidentoftheHealthCommissionoftheNationalAssembly
AlphaBalde
Senegal
ChiefoftheUnitforHealthInsurance,SupportCellforUniversal
HealthCoverage
SérigneDIOUF
Senegal
TechnicalAssistant,NationalProjectPAMAS2
BabacarLô
Côted'Ivoire
Healthspecialist,UNICEFCôted'Ivoire
AbdoulayeKonaté
Côted'Ivoire
DirectorofForecasting,Planning,andStrategy,MinistryofHealth
MamadouSamba
Ethiopia
RegionalDirector,USAID/HealthSectorFinancingReformProject
AntenehGenet
Organizing
Committee
MinistryofHealth,Morocco
EnnaciriM.
Organizing
Committee
MinistryofHealth,Morocco
ZerhouniMohammedWadie
Organizing
Committee
MinistryofHealth,Morocco
NadaBouarif
Organizing
FAHSCoP,SeniorFacilitator
AllisonKelley
23|P a g e Committee
Organizing
Committee
FAHSCoP,Facilitator
IsidoreSieulenou
Organizing
Committee
FAHSCoP,Facilitator
YambaKafando
Organizing
Committee
UNICEF/WCARO
JerômePfaffmann
Organizing
Committee
UNICEF/WCARO
JeanServais
Organizing
Committee
CAFSP
FahdiDkhimi
Organizing
Committee
ResultsforDevelopment(R4D),USA
MarilynHeymann
Organizing
Committee
ResultsforDevelopment(R4D),USA
AbebaTaddese
Expert
Professor,UniversityofMontreal,Canada
ValeryRidde
Expert
MCHIP/BroadBranchAssociates(BBA),USA
AlexErgo
Expert
EconomistandManagingDirectoratResultsforDevelopment(R4D),
USA
MartyMakinen
Expert
ProgramDirector,ResultsforDevelopment(R4D),USA
AmandaFolsom
24|P a g e Expert
OMS,Geneva,Switzerland
RikuElvainio
Expert
HeadofHealthSystemDevelopmentSupportUnit,NationalInstitute
ofPublicHealth,Cambodia
IrPor
Expert
DepartmentofHealthInsurance,MinistryofHealth,Vietnam
TranVanTien
Expert
InstituteofPublicHealth,Bangalore/Coordinator,RSBYevaluation,
Gujarat,India
TanyaSeshadri
Expert
CAFSP
BrunoMeessen
Expert
UNICEF/WCARO
MariameSylla
Expert
UNICEF/WCARO/SocialPolicy
ThiMinhPhuongNgo
PTF/ONG
DeputyDirectoratHealthDivision1ofJICA/HQ
MTaroKikuchi
PTF/ONG
LSHTM/FemHealth,UK
IsabelleLange
PTF/ONG
PharmAccess/SeniorProgramManager/Researcher
ChristineFenenga
PTF/ONG
PharmAccess/ProjectManager
MarthevanAndel
Regional
Organization
Projectcoordinator,UEMOA
JeanͲJacquesMongbo
Regional
Organization
Healtheconomist,UEMOA
BakaryͲSirikiKoné
Regional
Organization
Professional,OOAS
NamoudouKeita
25|P a g e Regional
Organization
Economist,OOAS
AlbertDiao
Memberof
FAHSCoP
ResearchAssistant,InstitutdeRechercheenSciencesdelaSanté
(IRSS)/BurkinaFaso
KadiatouKadio
Memberof
FAHSCoP
ChiefAdministrativeManager/NationalHealthInsuranceCoordinator
/Ghana
PhillipAsenahAkanzinge
Memberof
FAHSCoP
DeputyGeneralManager,UnionTechniquedelaMutualitéMalienne
(UTM)/Mali
CheicknaHamalaTouré
Memberof
FAHSCoP
ProgrammeCoordinator,GreatLakesInitiativeonAIDS(GLIA)/
Rwanda
RichardAlia
Memberof
FAHSCoP
ResearchAssistant,CenterforResearchonSocialPolicy(CREPOS)/
Senegal
MaymounaBa
Memberof
FAHSCoP
ResearchInstructor,UniversityofBambey/Senegal
PapaGalloSow
Memberof
FAHSCoP
Healtheconomist,AEDES/Belgium
MatthieuAntony
Memberof
FAHSCoP
Healtheconomist,InstituteofTropicalMedicine/Belgium
CatherineMarieKorachais
Memberof
FAHSCoP
HealthPolicy&ResearchAdviser,SavetheChildren/UnitedKingdom
LaraBrearley
Rapporteur
France
AntoniaMills
26|P a g e Morocco
Translation
RhrissiYoussef
Morocco
Translation
SifEddineBoukhef
Morocco
Translation
MarwanZerrouk
Morocco
Interpreter
FatimaLaaouina
Morocco
Interpreter
SaadiA.Taleb
Morocco
Cameraman,producer
ZahidAbdelaziz
27|P a g e Annex4ǦMarrakechDeclaration
MarrakeshDeclarationonaccesstohealthcareforthepoorest––our
commitment
We, as participants of the workshop on ““Equity in UHC: How to reach the
poorest””, we as members of the communities of practice affiliated to
““Harmonization for Health in Africa””, we as experts involved in health
systemsinAfrica,
Areconsciousofthedeepinequalitiesintermsofaccesstohealthcarein
ourcountries,
Are conscious of the impact of these inequalities on the health of the
poorest,
Areconsciousthataccesstohealthcareforthepoorestisdependenton
ourhealthsystems,
Areconsciousthatassistingtheindigents,theexcluded,thepoorestofthe
poorisinscribedinoursharedhumandignity,
AreenthusiasticaboutthegrowinginterestoftheAfricanStatesandtheir
partnersintheireffortstoimprovehealthcarecoverage.
We consider essential that this interest be translated as rapidly as
possible into actions and concrete measures in order to benefit the
poorest.
Consequently,
Wecommittotakingactionpersonally:
By supporting the implementation of strategies to improve access to
healthcareforthepoor.
By building on and accompanying the mechanisms to extend universal
healthcoverage.
Finally, by continuing to focus all our energy on facilitating equitable
accesstohealthcareinourcountries.
28|P a g e Annex5ǦWorkshopEvaluationsummary
Methodology
During the workshop, ‘‘live’’ evaluations were undertaken in order to understand the
participants’’ views of the content and format of the workshop activities. These evaluations
weredonewiththe““TurningPoint””technology,whichallowspollstobecarriedoutwiththe
useofMSPowerPointand““clickers””distributedtorespondents.
OnͲtheͲspot evaluations were conducted during three sessions of questions: on day 3 in the
morning,onday4inthemorning,andonday4intheafternoon.Eachtime,all51clickerswere
distributedamongtheparticipants.Therewerenotenoughclickerstocoveralltheworkshop
participants, but clickers were distributed in priority to the delegation participants (coverage
100%).Theresponseratewas80%onaverageforeachquestion(onaveragewereceived41
responses out of 51 distributed clickers). The response rate improved with each session (on
average,wereceived37responsesduringthefirstsession;40duringthesecondsession;and
46duringthelastsession).
Questions focused on the usefulness of the different sessions, the working groups on action
plans,andthegeneralqualityoftheworkshop.
Duringthetwofirstevaluationsessions,participantsansweredthequestionsbyclickingtheir
remotes, but results were not directly displayed. During the final evaluation on day 4 in the
afternoon, the feedback feature of the Turning Point software was employed: participants’’
resultswereimmediatelydisplayedonthescreenaftereachquestionhadbeenposed,sothat
thosepresentreceivedfeedbackfromthislastevaluationonthespot.
Results
Usefulnessofselectedactivities
Efforts were made to create a program in which the plenary sessions were stimulating,
informativeanduseful.Belowareparticipantassessmentsofafewofthesesessions,aswellas
thefieldtripondaytwooftheworkshop.
Firstsessionofquestions:
The presentation on the overview of mechanisms implemented in Africa during the first day
wasconsideredusefulorveryusefulby83%oftherespondentswhile11%founditminimally
useful or not useful at all. The field visit on Day 2 was very appreciated as 100% of the
respondentsfounditusefulorveryuseful.
29|P a g e Secondssession:
OnDay3
3,thepanel on‘‘identifyyingthepoorest––approoachesandcchallenges’’w
wasfoundu
useful
or very useful
u
by 77
7% of the re
espondents. Comparativvely less inteerest was reegistered fo
or the
session on
o methodss to monitor and meassure equity: the presen
ntation on ‘‘‘‘how to mo
onitor
equity’’w
wasfoundussefulorveryusefulbyon
nly53%ofthherespondeents.
Thirdse
ession:
Participantsareshow
wntobemo
oreintereste
edinthepoliticalissuesspresented duringtherround
tablewitthmembersofParliamentonday4.Thissessionnwasfoundusefulorveeryusefulbyy89%
oftherespondents.
Figure2:Resultsreggardingtheu
usefulnesso
ofactivities
A) Presentation:overviewo
of
mechanisms
m
implemente
edin
Africa:summ
A
maryofexpe
eriences
Day1
D
B) Fiieldvisit
Day2
D
C) Panelon‘‘ide
entifyingthe
epoorest––
approachesa
andchallengges’’
Day3
D
30|P a g e D) Presentation‘‘howtomo
onitor
equity:methodsandcassestudy
frromSenegal’’
Day3
D
E) Roundtable
R
withmembersof
Parliament
Day4
D
Usefuln
nessofthe
eworkinggroupson
nactionpllans
A core feature
f
of this
t
worksh
hop was the
e work withhin and between coun
ntry delegattions.
Participantswereaskedastowh
hethertheyvaluedthis workandin
nparticulartthetaskthattwas
definedfforthem:th
hecreationo
ofanactionplanonequ ityinUHCfo
ortheircoun
ntry.
Session1:
Thediscu
ussionbetweencountryypairsonDaay1wasfouundusefulo
orveryusefu
ulfor78%o
ofthe
responde
ents.
Session2:
90% of the
t respond
dents agreed
d or stronglyy agreed wiith the stateement that the small ggroup
discussio
onsonthefie
eldvisitswe
eredynamicandstimulaating,and722%oftherespondentsffound
itpertine
entorveryp
pertinenttobrainstormo
onanactionnplanfortheeircountry.
Session3:
edresponde
entsanswere
edthatthe actionplan theyworkeedonwould
dvery
50%oftheconcerne
likely plaay a role in their country’’s strateggies after thheir return. 33% answeered that itt was
somewhaatlikely,while17%thou
ughtthatitw
wasnotveryylikelyorno
otlikelyatall.
31|P a g e Figure3:Resultsreggardingtheu
usefulnesso
oftheworkin
nggroupsonactionplaans
A) Howusefulw
H
wasthediscu
ussion
betweencou
untrypairs
Day1
D
B) Themorning’’’’sgroupworkonthe
fe
eedbackoftthefieldvisiitswere
dynamicandstimulatingg
Day3
D
C) Howpertinen
H
ntisittobraainstorm
onanactionplanforyou
ur
co
ountry?
D) Howlikelyis
H
itthatthisaaction
planwillplayyaroleinyo
our
co
ountry’’sstra
ategiesafteryour
re
eturn?
32|P a g e Genera
alevaluatio
on
x
x
x
x
x
73% of the respondents
r
s agreed or strongly agreed with the statement that theyy had
enough time
e to exchange with oth
her participaants inform
mally about equity and UHC
Days1and2
2).
(D
95%foundth
hatasofday3,thecon
ntentandthhelevelofeexchangehaadbeenthoughtͲ
provokingforrthem.
95% agreed or stronglyy agreed with
w
the staatement that, overall, the processs of
describingtheirowncountrychallen
ngescaused themtorefflectandthinkconstructtively
ountry’’ssitu
uation.
abouttheirco
98%agreedo
orstronglyagreedwithtthestatemeentthatthew
workshophadbeenvalu
uable
fo
orthemoverall.
91%agreedo
orstronglyaagreedwiththestatemeentthattheyyexpectedttofollowup
pwith
pantsfromtheworkshopafterwards.
otherparticip
When assked if they would join the ‘‘Financiial Access’’ C
CoP after th
his workshop
p, 24% answ
wered
they werre already members;
m
12% respond
ded «What’’’’s that?» att the end o
of the worksshop:
we’’reno
otsurewhethertheywe
ereplayingalongwithouurjokeorsttilldidn’’tkno
owaboutit!!64%
answered
dtheywould
djoin.
Figure4:Generalevaluation
A) Iamfindinge
enoughtime
eto
exchangewitthotherparrticipants
in
nformallyab
boutequityaandUHC
(D
Days1and2
2)
B) So
ofar(day3)),havetheccontent
andlevelofe
exchangebe
een
th
houghtͲprovvokingforyo
ou?
33|P a g e C) Overall,thep
O
processofdescribing
ourownchalllengescaussedmeto
re
eflectandth
hinkconstru
uctively
aboutmyow
wncountry’’ssituation
D) Thisworksho
ophasbeenvaluable
fo
ormeoverall
E) Iexpecttofo
ollowupwithother
participantsffromthewo
orkshop
affterthemee
eting
F) Willyoujoin
W
the‘‘Financiial
Access’’CoPa
A
afterthiswo
orkshop?
34|P a g e Limitsofthisanalysis
x
x
x
Questions were prepared upon consultation of others in the facilitating group, but
normallypreparedatthelastminuteandthequalityofthequestionsvaried.
Theturningpointtechnologywasnewtothefacilitatorsofthequestionnaires.
TheturningpointtechnologydoesnotallowopenͲendedquestionstobeposed.Forthis
reason, an anonymous postͲworkshop online survey with both open and closed
questionswasdevelopedinordertogetabetterunderstandingofparticipants’’overall
perceptions of the workshop. The objectives were the same: to improve future
community of practice workshops and better understand the capacities of the CoP in
thisfield.ThethemesofthepostͲworkshopsurveyquestionsareorganizedasfollows:
demographics, expectations, format of the workshop, participants, overall perception,
followͲupafterleaving,andrecommendationsforimprovement.Thetimetocomplete
the survey was estimated at approximately 10Ͳ20 minutes. The questionnaires were
offered separately in English and French on the www.formsite.com (using an ITM
account) platform that allows the results to be exported to Excel. So far only 20
responseshavebeenobtainedwhichwillbeanalyzedinthecomingweeks.
35|P a g e