J.11_Benin_Private_Health_Sector_Assessment.pdf

March 2013

This document was produced for review by the United States Agency for International Development. It was prepared by Carlos Cuellar, Andrew Carmona, Andrea Harris, and Piotr Korynski for the Strengthening Health Outcomes through the Private Sector (SHOPS) project.

BENIN PRIVATE HEALTH

SECTOR ASSESSMENT

Recommended Citation:

Cuellar, Carlos, Carmona, Andrew, Harris, Andrea, Korynski, Piotr. March 2013. Benin Private Health Sector Assessment. Bethesda, MD: Strengthening Health Outcomes through the Private Sector Project, Abt Associates Inc.

Download copies of SHOPS publications at: www.shopsproject.org

Cooperative Agreement: GPO-A-00-09-00007-00

Submitted to: Marguerite Farrell, AOTR

Bureau of Global Health Global Health/Population and Reproductive Health/Service Delivery Improvement United States Agency for International Development

Abt Associates Inc.

4550 Montgomery Avenue, Suite 800 North Bethesda, MD 20814 Tel: 301.347.5000 Fax: 301.913.9061 www.abtassociates.com

In collaboration with:

Banyan Global Jhpiego Marie Stopes International

Monitor Group O’Hanlon Health Consulting

DISCLAIMER

The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States government.

BENIN PRIVATE HEALTH

SECTOR ASSESSMENT

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TABLE OF CONTENTS

Acronyms ............................................................................................................................ v

Acknowledgments ............................................................................................................ vii

Executive Summary ........................................................................................................... ix

1. Background

1.1 Introduction

1.2 Benin’s Health System

1.3 The private Health Sector in Benin

1.4 Health Expenditures

1.5 Donor Environment

1.6 Overview of report

2. Scope and Methodology of Assessment

2.1 Scope of Work

2.2 Methodology

3. Policy Environment

3.1 Background

3.2 Policy Environment for Services

3.3 Policy Environment for Products

3.4 Civil Society Organizations

3.4.1 Professional Associations

3.4.2 Advocacy Organizations

4. Service Provision in the Private Sector

4.1 Analysis of Services

4.1.1 Maternal and Newborn Health

4.1.2 Family Planning

4.2 Organization and Size of the Private Sector

4.3 For-Profit Sector

4.4 Not-For-Profit Sector

4.4.1 Faith-Based Organizations

4.4.2 Associatifs/NGO-BASED NETWORKS

5. Pharmaceutical Supply and Products

5.1 Background

5.2 Commercial Sector

5.3 Subsidized Sector

5.4 Distribution

5.5 Pricing and Stock Availability

5.6 Analysis of Pricing variations and Sales estimates for Family Planning Products ... 54 iii

6. Access to Finance

6.1 Background

6.2 Key Business Features of Private Providers

6.3 Business Skills and Management Capacity of Private Providers

6.4 Financing Needs of Private Providers

6.5 Financing Constraints

6.6 Demand for Financing

6.7 Financial Institutions

6.8 Potentiality for Development Credit Authority Guarantees

7. Health Insurance

7.1 Background

7.1.1 Health Expenditures

7.2 Technical Capacity and Management at the National Level

7.3 Current Health Insurance Schemes

8. Recommendations

9. Conclusion

10. References

Annex A: Scope of Work

Annex B: List of Contacts v

ACRONYMS

ABMS Association Béninoise de Planification Familiale et la Communication pour la Santé

ABPF Association Beninoise pour la Planification Familiale

AMCES Association des Œuvres Médicales Privées Confessionnelles et

Sociales au Benin

AMM Authorisation de Mise sure le Marche

ANAM Agence National d’Assurance Maladie

ASA-Benin Association of Insurance Companies in Benin

CAME Centrale d’Achat des Medicaments Essentiels et Consommables

CEBAC STP Coalition des Entreprises Béninoises et Associations contre le Sida, la

Tuberculose et le Paludisme

CFR West African Franc (currency)

CTM Commission Technique des Medicaments

DCA Development Credit Authority

DHS Demographic Health Survey

DNSP Direction Nationale de Santé Publique

DPMED Direction des Pharmacies et du Medicament

DPT Diphtheria, Pertussis, Tetanus

EDL Essential Drugs List

EKG Electrocardiogram

EPI Extended Program of Immunization

FCFA West African Franc (currency)

FNRB Fonds national de la retraite du Bénin

FP/RH Family Planning/Reproductive Health

GAPOB Groupement d’Achat des Pharmacie d’Officine du Benin

GDP Gross Domestic Product

GHI Global Health Initiative

GNI Gross National Income

HIV/AIDS Human Immunodeficiency Virus Infection / Acquired

Immunodeficiency Syndrome vi

HSA Health Sector Assessment

ICON International Contraceptive & SRH Marketing Ltd.

ICT Information and Communication Technology

IMCI Integrated Management of Childhood Illness

IMPACT Integrated Project to Promote Family Health and HIV/AIDS Prevention

IPPF International Planned Parenthood Foundation

ITN Insecticide-treated Nets

IUD Intrauterine Device

IV Intravenous

LARM Long-acting Reversible Method

LNCQ Laboratoire National de Contrôle de la Qualité

MCDI Medical Care Development International

MCH Maternal and Child Health

MFI Microfinance Institution

MNCH Maternal, Neonatal, and Child Health

MOH Ministry of Health

NGO Nongovernmental Organization

NHA National Health Accounts

OC Oral Contraceptives

PPP Public-Private Partnership

PSA Private Sector Assessment

PSI Population Services International

QA Quality Assurance

RAMU Régime d’Assurance Maladie Universel

ROBS Réseau des ONG Béninoises de Santé

SBM-R Standards Based Management and Recognition

SHOPS Strengthening Health Outcomes through the Private Sector

STI Sexually Transmitted Infection

TB Tuberculosis

UNDP United Nations Development Programme

UNFPA United Nations Population Fund

UPEPHAR Union Beninoise des Pharmaciens du Benin

USAID United States Agency for International Development

WHO World Health Organization vii

ACKNOWLEDGMENTS

The authors would like to particularly thank several individuals who contributed to this assessment. We give a deep merci beaucoup to Pascal Soglohoun, Dr. Irenée Kotchofa, and

Rosemonde Adjagboni, our Beninese colleagues whose keen interest in and knowledge of the private health and financial sectors was invaluable during the assessment. We appreciate the support of the Benin field office of the USAID-funded Africa Indoor Residual Spraying (AIRS), especially Josephine Tossa and Alliance Tossou, for their assistance in supporting the PSA team with all manners of in-country logistics. We wholeheartedly thank our tireless driver, Maxime, for the countless hours he spent in the car. We are thankful to the active engagement and guidance from the USAID/Benin family health team, particularly Michelle Kouletio, Milton

Amayun, and Cheryl Combest. We are grateful for the participation and support of the

PSI/ABMS organization, particularly Megan Wilson and Leger Foyet. The authors extend many thanks to Yann Derriennic for his last-minute assistance on the assessment, as well as to

Christina Juan for her hard work on the extensive DHS analysis, literature reviews, and French translation. We are beholden to the thorough and insightful reviews of SHOPS Deputy Director and colleague Caroline Quijada. Most importantly, we are obliged to thank the more than 100 inspiring health providers, businessmen and women, public officials, development practitioners, and other important stakeholders who spoke with us and shared their important thoughts about more effectively partnering with the private sector to improve the health and well-being of

Beninese.

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EXECUTIVE SUMMARY

Independent since 1960, Benin is a West African Francophone country with a population of 9.3 million. The bulk of Benin‘s economy stems from agriculture, with 56 percent of the population either working or involved in this industry. Urbanizing at a rate of 4 percent per year, Benin is currently 42 percent urban and by some estimates is expected to reach a rate of 50 percent by

2017. Benin ranks 166 out of 187 countries on the Human Development Index, with 39 percent of the population living below the poverty line (UNDP 2012.

The existence of a private health sector is a relatively new development in Benin. At the beginning of the 1980s, few private health care centers existed in Benin‘s health care system landscape. However, in 1986, a halt in public health care recruiting set the stage for a large expansion of private practice in the country. Private health care centers launched in the 1980s came mostly in the form of faith-based religious institutions and structures located in urban areas. Other private health centers sprang up on an ad hoc basis until 1997 when Law 1997-020 authorized the private practice of medicine in Benin (2006 HSA).

Since 1997, Benin has experienced an explosion of growth in private health practice. According to the 2012 Benin Health Systems 20/20 assessment, health sector human resources in Benin number 18,078 professionals, 25 percent (approximately 4,500 people) of which are located in the private sector. Formal registration of private practice with the Ministry of Health (MOH) remains a major issue, however, as shown by a 2005 survey of 231 private providers that indicated only 12 percent were authorized to practice. Restrictive regulatory and licensing processes, as well as a historically public-oriented health environment, have resulted in both a lack of incentive to register as formal health practices and a rapid growth of the informal private health sector.

USAID/Benin seeks practical strategies to strengthen collaboration between the public and formal private health sectors in Benin. For 2011–2015, USAID/Benin has set forth as a strategic priority the strengthening of private sector involvement to improve health outcomes in Benin. To that extent, in mid-2012 USAID/Benin commissioned the Strengthening Health Outcomes through the Private Sector (SHOPS) project to undertake an assessment of the private health sector in Benin to assist USAID and other stakeholders with developing a strategy for further engaging the private sector. The strategy will complement and augment current efforts within the public and private sectors with a focus on family planning, maternal and child health, urban populations (particularly the urban poor), and existing service provider networks.

The assessment focused on five key thematic areas: policy environment, provision of services, pharmaceutical products and supply, access to finance, and health insurance. The scope of the assessment was as follows:

• Determine the size, scope, and scale of private sector providers in Benin.

• Assess the policy and regulatory environment for private provision of health products and services.

http://www.healthsystems2020.org/files/1917_file_Benin_Pilot_Test_Assessment_Report.pdf x

• Assess business and financing needs of the private health sector with an emphasis on networked facilities in the Protection de la Famille (ProFam) franchise and the

Association of Private Faith-based Medical and Social Providers of Benin (AMCES).

• Identify synergies with already existing USAID field support activities focused on improving health outcomes in Benin.

• Identify opportunities to increase access to private sector health financing options by examining current initiatives.

In the context of this assessment, the ―private health sector‖ includes a diversity of actors— nongovernmental organizations that include both faith-based organizations and associations, as well as for-profit health care businesses ranging from treatment/prevention and pharmaceutical distribution, to financing and insurance. Traditional healers were determined to fall outside of the scope of work for the present assessment, as specified by USAID/Benin. A separate study on the impact traditional healers have on health care provision, if undertaken by USAID, would likely yield important insights on consumer behavior and out-of-pocket expenditures for health.

FINDINGS

Key findings of the team‘s assessment can be found in Table 1. The findings are organized by the five major health areas analyzed (policy environment, service provision, pharmaceutical supply, access to finance, and health financing), and represent an important overview of the strengths and weaknesses of each health area. Additional details on the points in Table 1 can be found in their respective sections within the body of the report.

Table 1: Key Findings

Finding Area Strengths Weaknesses

General The private health sector is growing in prominence and there is growing recognition of the private sector as an important player in the Benin health market.

The private sector has significant untapped potential to speed progress toward providing better health care access for Benin‘s population.

Benin‘s post-French colonial and post-socialist heritage have left a public health system reliant on regulation and centralized decision making. This creates an impediment to growth of the private health sector.

Forty-six percent of health sector transactions are occurring through out-of-pocket spending (compared to a regional average of 40 percent), 93 percent of which happens through the private sector (regional average of 62 percent).

Policy environment Of the professional orders in Benin, the Order of Pharmacists is strong and has the potential to enact significant change. However, it has a dual role with potential for conflicts of interest.

The private health sector is overregulated, in the sense of being over controlled and is fueling the growth of the informal sector.

There are major restrictive regulations in current health xi

Advocacy organizations such as

ROBS, CEBAC STP, and the

Association of Private Clinics are well positioned to take on roles of coordinating and advocating for private sector medical and non-medical practices.

legislation.

The formal private sector is operating on an individual basis, and the policy environment is not favorable for establishing group practices or provider networks.

Most profession medical associations

(―Ordres‖) have limited ability to respond to registration and licensing requirements, mostly due to a lack of time to conduct inspections of prospective member facilities.

There is a high potential for conflict of interest between members of professional associations and applicants for registration of health care facilities and/or pharmaceutical products (i.e., for approval of potentially competitive multiple locations serving one catchment area).

Public agencies dominate in initiating and overseeing the implementation of public-private partnerships.

Service provision AMCES is a significant actor in the nonprofit health sector with 18 primary health care centers (Centre de Santé) and 10 hospitals that have succeeded in implementing a public-private partnership with the MOH.

ProFam network of 50 members and

100 affiliates is an effective provider of family planning and other priority health services in the private sector, but its growth is dependent on registered providers.

Business model of the commercial sector is ―low-volume, high-unit cost, low-margin.‖

Most likely, uneven quality exists in service provision as a result of a lack of quality assurance systems in the commercial sector.

Pharmaceutical supply Since the restructuring of CAME, stock outs are now significantly less frequent than they were earlier;

however, challenges still remain in ensuring a regular supply to private sector pharmaceutical dispensary points in locations outside of the main metropolitan center of Cotonou.

Professional stove piping acts as a barrier to collaboration between pharmacists and other providers. The strict segregation of 'professional identities' between pharmacists and the other professions (i.e., service providers) hinders the opportunity for creative engagement across these professional boundaries.

There is an unbalanced pharmaceutical human resources spectrum and a lack of professional xii cadre preparation.

Limited understanding of market segmentation value among public officials leads to limitations on consumer choice and sector growth

Access to finance One Development Credit Authority

(DCA) guarantee with EcoBank is active, and there is interest for additional DCA guarantees among other banks.

There is a strong demand for finance among private health providers.

The need for financing is high among private providers in Benin, as most facilities are seeking to improve their facilities, upgrade or expand the premises, or acquire new equipment.

At present, there is practically no external financing available for new and early stage private health businesses.

A lack of or weak collateral, as well as weak management skills and lack of business training, severely limits borrowing ability for most private providers.

Bank and MFI lending in the private health sector is sporadic and limited.

Health insurance A policy decision has been made to institute a universal health insurance system (RAMU).

There is a history and general acceptance of community-based health insurance in Benin that is well understood, is consonant with the local culture, and can be strengthened.

RAMU faces a number of challenges from a private sector perspective, such as a lengthy and bureaucratic accreditation and quality improvement process and a lack of confidence in timing and transparency of public sector-managed payments. It has a weak legal and institutional basis on which to operate.

An inadequate supply of health service providers undermines the introduction of a universal health insurance.

Lack of actuarial expertise hinders implementation of health financing reforms.

Reaching the informal sector is a major challenge. Mutuelles are weak:

there is no plan to take them to scale, they have weak management and a lack of standardization of services, and they are withering due to lack of support and an inability to ensure access to quality providers.

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RECOMMENDATIONS

Key recommendations of the assessment are summarized in Table 2. There are five major recommendations, each with its own set of actionable sub recommendations. Many of the recommendations are relevant to multiple stakeholders; the suggested lead agencies best able to move the recommendations forward are listed in the right most column. Additional details on most of these recommendations can be found in their respective sections within the body of this report. These recommendations can also be found in Section 8.

Table 2: Key Recommendations

Recommendation

Area Recommendation Lead Agency

(1) Grow the formal sector by streamlining registration and licensing processes for businesses and supporting provider networks

Initiate a policy dialogue with the MOH to streamline the registration process and improve compliance with/enforcement of officially set time limitations on the review process. The creation of a one-stop-shop or

―Guichet unique‖ approach, where providers can take care of all aspects of business registration and licensing, could be part of the solution.

USAID

Provide amnesty for current qualified but unregistered informal providers/ facilities. This is necessary to encourage existing facilities to submit an application for registration, especially as it pertains to future growth of the

ProFam network.

MOH

Support a mechanism to identify and support providers in becoming registered. Give technical assistance to an organization, such as ABMS or another that has a vested interest in the formal health sector, to take on this role.

Ensure that formal registration qualifies a provider to participate in RAMU.

USAID/ABMS

Remove barriers in order to convert private sector clinics into high-volume, high-quality, low-unit cost facilities. Start and maintain a dialogue with MOH and professional orders to relax the constraints on marketing and promotion of health services, deregulate prices so that they are more market-based, and develop a package of incentives to promote group practices and provider networks.

MOH/

Professional

Orders

Strengthen the family planning program in the AMCES network. Link AMCES to ABMS and other FP supply actors in order to increase the volume of FP products at their health centers and hospitals, where such products are allowed, and strengthen FP counseling programs and referrals to emphasize informed choice.

USAID

Strengthen the financial sustainability of ABPF through targeted assessments. Following on Engender Health‘s technical assistance to ABPF, support development of a

USAID

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Area Recommendation Lead Agency strategic plan, an investment plan, and business plans aimed at reducing financial vulnerability of the organization while preserving their social mission.

(2) Strengthen the role of the private sector at the national policy level and through advocacy groups

Identify a high profile private sector “champion” and an

MOH counterpart to organize and coordinate regular dialogue meetings between the MOH and private sector stakeholders.

USAID/MOH

Strengthen the advocacy capacity of the professional orders to participate in the MOH‘s health systems strengthening efforts. Give technical assistance to strengthen strategic plans, role as a secretariat of its members, and coordination of training and other benefits for members.

USAID

Work with thought leaders within the professional associations to separate and clarify regulatory roles from business interests of the members so as to avoid inherent conflicts of interest, especially within the Professional

Association of Pharmacists and Professional Association of

Physicians.

USAID

Improve private providers‟ understanding of government standards and of provider rights surrounding enforcement of time frames for facility/product registration and dossier review. Support an association or NGO to educate providers about these rights and responsibilities.

USAID

Assess the feasibility of setting up an independent, NGO-led quality standards and quality assurance system in private sector facilities. Strengthen the role of supervision of

QA systems and compliance with standards as part of a certification system. Consider support (in the longer term) for the creation of a self-regulating ―grading‖ system for private providers.

USAID

Provide technical assistance to ROBS to make a thorough sustainability assessment and strategic plan.

USAID

Support CEBAC STP with targeted technical assistance in order to integrate FP services in the already existing workplace clinics. Make a strategic plan aimed at inclusion of workplace clinics in the ProFam network.

USAID

Include the Association of Private Clinics in any policy dialogues aimed at streamlining the health facility registration process or establishing QA systems and PPPs in support of priority programs, especially FP/RH.

xv

Area Recommendation Lead Agency

(3) Streamline registration, licensing processes, and business operations for pharmaceutical businesses and products

Enforce timely and rational review of pharmaceutical product registration dossiers through technical assistance to MOH. Ease restrictive limitations on the level of product competition, which significantly hampers private sector engagement and end-user choice in products.

USAID/MOH

Advocate with MOH to eliminate conflict of interest associated with the quasi-regulatory role(s) of Orders of

Pharmacists, Midwives, and Physicians, by separating regulatory function(s) in product and facility registration dossier review from other (client-oriented) functions.

USAID

Conduct in-depth study of pharmaceutical product flows to eliminate inefficiencies. Simplify and harmonize pharmaceutical flow through the supply chain.

MOH

Provide technical assistance to the Commission Technique des Medicaments in order to evaluate current government-set pharmaceutical margins and their effect on private wholesalers, ensuring that wholesalers are not inadvertently

‗squeezed‘ by changing fixed costs and exchange rate fluctuations. Support the commission to conduct quarterly reviews of pricing throughout the supply chain.

USAID

Provide technical assistance to ABMS, CAME, and other wholesalers and retailers on market-based pricing and costing.

USAID

Design and implement targeted training to increase the capabilities of supply chain managers in the labor force.

This is a promising arena for promoting PPPs with international industry.

USAID

Create incentives for private pharmaceutical providers to collaborate with other health professionals to better provide consumer access to pharmaceuticals in remote areas of the country. This could include jointly managed facilities or outreach activities in underserved locations, operating ‗branch‘ dispensaries within faith-based or public health care facilities, or promotion of collaboration between pharmacists and providers on stock estimation in order to avoid stock availability issues.

MOH

(4) Improve access to finance and business capacity of providers

Design access to finance programs with banks and MFIs to strategically provide an incentive for business formalization. Stimulate a more rational (desired) mix of health providers by carefully channeling targeted and supervised loans to the types of providers that would advance health outcomes in the priority geographic areas of the country.

USAID

Provide technical assistance to EcoBank‟s DCA borrowers receiving funds under the USAID guarantee.

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Area Recommendation Lead Agency

This could be structured as pre-borrowing assistance as well as post-borrowing assistance provided on a one-to-one basis to the funded clinics.

Arrange two lines of additional credit for private health sector providers with Bank of Africa and FECECAM, in order to provide longer term funding to smaller providers in rural and peri-urban areas.

USAID

Strengthen business capacity by launching business management trainings and by providing direct technical assistance to increase management capacity of private providers, including developing strategies and business plans, mentoring and coaching senior managers, and facilitating access to finance.

USAID

(5) Foster the growth of private sector health financing mechanisms

(health insurance)

Support the development of RAMU and its mechanisms, and, in particular, ensure that private sector providers are taken into consideration. Support a private sector working group serving as an advisory body to the government and RAMU, and playing the role of the unified voice of the private sector. Provide technical resources to develop evidence-based arguments to support the terms and conditions of the private sector participation in RAMU.

MOH

Build the capacity of mutuelles through support to national level efforts focused on networking and professionalization. Streamline the process of creation and operation of a local mutuelle through development of uniform policies, procedures, and documentation; a centralized operational platform for data processing and management; and assistance to market and promote the health insurance among low-income populations. Support the creation of unions of mutuelles on a regional basis, which will have the responsibility of both starting new mutuelles and supporting existing mutuelles.

USAID

Support the provision of actuarial expertise to ANAM to underwrite evidence based, and appropriately priced, coverage packages for the formal and informal sectors

Facilitate this process by engaging Actuaries without

Borders and other similar organizations.

WHO / Swiss

1. BACKGROUND

1.1 INTRODUCTION

Independent since 1960, Benin is a West African

Francophone country with a population of 9.3 million. The bulk of Benin‘s economy stems from agriculture, with 56 percent of the population either working or involved in this industry.

Urbanizing at a rate of 4 percent per year, Benin is currently 42 percent urban and by some estimates is expected to reach a rate of 50 percent by 2017

(see Figure 1). Benin ranks 163 out of 177 countries on the Human Development Index, with

39 percent of the population living below the poverty line. The average life expectancy at birth is 56 years.

Child health indicators in Benin have been improving over the course of the last decade, yet much work remains to be done. The under-five mortality and infant mortality rates are 106 and

68 per 1,000 live births, respectively, and have been steadily decreasing, down from 120 and 76, respectively, in 2006 (World Bank 2011). According to GHI‘s 2011 strategy paper, malaria is the number one killer of all children under five, constituting 40 percent of outpatient health center visits, and is responsible for 23 percent of all under-five deaths in 2008. As of 2010, 83 percent of children are DPT immunized, with a 69-percent measles vaccination coverage rate. The new

2012 Benin Demographic Health Survey (DHS) preliminary report indicates that 28.4 percent of children under five test positive for malaria, and 44.6 percent are severely or moderately stunted due to chronic malnutrition—a rate that has worsened significantly in the past decade.

Figure 1: Trend in Urbanization (% GROWTH)

Source: World Bank databank, via Trading Economies https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&ved=0CDcQFjAA&url=http%3A%2F%2Fwww.ghi.gov%2Fdocuments%2Forganization%2F178896.pdf&ei=vprcUIXWE4u10QHesIGABw&usg=AFQjCNE01ggXKx3J-xg8WwXZ_TmAVzisUw&sig2=ZU1FeoVA7iG08Pbr51scJg&bvm=bv.1355534169,d.dmQ http://www.measuredhs.com/pubs/pdf/PR24/PR24.pdf http://www.tradingeconomics.com/benin/urban-population-percent-of-total-wb-data.html

The fertility rate in Benin decreased from 5.6 in 2006 to 4.9 in 2012, while maternal mortality dropped to 350 per 100,000 live births in 2010, down from 770 two decades earlier. A skilled attendant is now present at 84 percent of live births, up from 78 percent in 2006 (DHS 2012).

With regard to family planning, Benin hosts a 30-percent unmet need for contraceptives among married women aged 15–49. The recent release of the DHS Benin 2012 preliminary report seems to indicate that a change in contraceptive use among married women aged 15–49 is stagnant at best: the contraceptive prevalence rate among that group fell to 12.9 percent, from 17 percent in

2006; however, the modern contraceptive prevalence rate rose from 6.0 to 7.9 percent.

According to 2006 DHS data, 39 percent of males aged 15–24 reported using condoms.

Benin‘s gross domestic product (GDP) is $7.3 billion, with a GDP per capita of $737 and a GNI per capita of $1,630. Benin has experienced between 3 percent and 5 percent annual GDP growth since 2003 (Figure 2). The country ranks 119 out of 144 economies, according to the World

Economic Forum‘s Global Competitiveness Report 2012–2013. According to this report, the most problematic factors for doing business are (1) corruption (23.8 percent), access to financing

(17.2 percent), tax rates (4.0 percent), inadequate supply of infrastructure (11.1 percent), and tax regulations (6.6 percent).

Figure 2: GDP Growth (Annual %)

Source: World Bank databank

Benin has the potential to reach some of the United Nation‘s Millennium Development Goals

(MDG), namely achieve universal primary education, ensure access to sanitation and safe drinking water, develop an open and nondiscriminatory trade and financial system, and reduce its debt in a sustainable manner. Benin is still lagging significantly behind in the goals of eradicating extreme poverty and hunger and reducing biodiversity loss, and has large disparities when compared to other regional countries in the MDG of promoting gender equality, reducing child mortality, improving maternal health, and combating HIV/AIDS, malaria, and other diseases (United Nations 2010).

http://www.measuredhs.com/pubs/pdf/FR197/FR197.pdf http://www3.weforum.org/docs/WEF_GlobalCompetitivenessReport_2012-13.pdf http://data.worldbank.org/indicator/NY.GDP.MKTP.KD.ZG/countries/BJ-zf?display=graph http://web.undp.org/africa/documents/mdg/benin_june2010.pdf

1.2 BENIN’S HEALTH SYSTEM

According to Benin‘s Ministry of Health (MOH), policy and effective strategy around health outcomes and development are indispensible preconditions to the economic development of a nation. Although 77 percent of Benin‘s population lives within three miles of a health facility, only 45.4 percent utilizes such facilities. Despite having adequate geographic coverage by health facilities, only 79 percent of

Benin‘s zones sanitaires (health zones) are functional

(Health Systems 20/20 2012). Access to maternal and child health (MCH) care, pharmacies, and private providers is not equitable, with significantly lower access for rural populations.

In the National Health Policy for Health Sector

Development published in 1999, the MOH lays out a decentralized system of health consisting of central/national, intermediate/departmental, and peripheral levels. The central level includes the MOH and its directorates, as well national reference hospitals. The intermediate level includes departmental directorates for health and departmental referral hospitals. The peripheral level includes health zones, which contain zonal reference hospitals, commune health centers, private health facilities, and village health units (Figure 3).

Figure 3: Health System in Benin

Source: 2012 HS20/20 Benin HSA

The country‘s 12 departments are split into 34 zones sanitaires (or health zones) (see map in section 1.2). These health zones contain anywhere from one to four communes and are managed by health zone committees and health zone management teams. From the smallest to largest facility, each zone has arrondissement health centers, commune health centers, and a zonal http://www.refips.org/files/afriquesubsahara/Politique_Promotion_Sante_Benin.pdf http://www.refips.org/files/afriquesubsahara/Politique_Promotion_Sante_Benin.pdf hospital. The health zone oversees all public and private health entities within its zone, including private not-for-profit and for-profit hospitals, clinics, and pharmacies.

1.3 THE PRIVATE HEALTH SECTOR IN BENIN

The existence of a private health sector is a relatively new development in Benin. At the beginning of the 1980s, few private health care centers existed within Benin‘s overall health care system landscape; most health care providers were hired by the state after completion of their studies. In addition, there was a strong Marxist-Leninist orientation in the country during that time period, when the government of Benin was closely allied with USSR, Cuba, and Angola.

However, in 1986, a halt in public health care recruiting set the stage for a large expansion of private practice in the country. Private health care centers launched in the 1980s came mostly in the form of faith-based religious institutions and structures located in urban areas. Other private health centers sprang up on an ad hoc basis until 1997 when Law 1997-020 authorized the private practice of medicine in Benin (2006 HSA).

Since 1997, Benin has experienced an explosion of growth in private health practices. The private health sector currently consists of commercial for-profit facilities, nonprofit faith-based and nongovernmental organization (NGO) facilities, and public-private partnerships. According to the 2012 Benin health sector assessment, health sector human resources in Benin number

18,078 people, 25 percent (approximately 4,500 people) of which are located in the private sector. In 2011, the MOH released a list of registered private sector practices indicating the existence of 189 medical practices, 227 midwife practices, 69 nurse practices, and 25 dental practices. As of 2012, the professional association of doctors in Benin had 850 private sector doctors registered as members, the association of midwives listed more than 500 private sector members, and the association of nurses, although without a list, claimed to have an exceedingly large membership as well. There are approximately 15–20 private commercial or NGO-owned hospitals in Benin, and the country hosts approximately 240 registered pharmacies and five major private wholesalers of drugs. Most of the private sector is found in the south of the country, particularly in the communes of Cotonou, Porto-Novo, and Abomey-Calavi. While formal private health sector practices are thought to number over 1,000, it is commonly understood that the informal unregistered sector (determined to be outside the scope of this assessment), made up of traditional healers, unqualified practitioners, and unregistered clinics, is exceedingly outpacing the formal sector in growth.

Because of its post-colonial and post-communism heritage, the public health architecture in

Benin relies heavily on regulation and centralized decision making, as opposed to market forces, to determine pricing, supply, and labor in the health care sector. This over-reliance on regulation creates a strong impediment to growth of private sector health care provision. It is illustrated in numerous challenges currently facing the sector. For example, licensing and registration of private practice is a major issue in Benin. A 2005 survey of 231 private health practitioners by the DNSP in Benin found that only 12 percent were formally registered with the MOH. In order to be licensed and registered in Benin, medical and paramedical professionals must petition their respective Medical Boards. Comprehensive laws governing the licensing of health providers and the establishment of private practices are in place, though such regulations are not sufficiently enforced, making it easier for physicians and other health workers to informally join the private

55.75

52.07 52.07

47.72 47.21 46 44.7 42.77

46.77

Jan-02 Jan-04 Jan-06 Jan-08 Jan-10 sector. This leads to a handful of issues, such as a low quality of care caused by a lack of rigorous screening, supervision, and recertification of health care providers. Furthermore, biannual MOH inspections of most private health facilities do not occur, due to insufficient human and financial resources. Although it is illegal to practice in both the public and private sectors, dual practice appears to be relatively common among providers (2006 HSA).

1.4 HEALTH EXPENDITURES

Expenditures on health care in Benin dramatically changed since the country‘s political independence in 1960. Following the example of other developing countries, Benin‘s financial access to health care went from being free to becoming a mechanism of cost recovery and subsidies for vulnerable groups, then finally to a system of universal health insurance (Régime d‟Assurance Maladie Universel [RAMU]) in 2011. It was envisioned that RAMU would greatly enhance access to health services and facilitate the scaling up of health interventions through offering many free health services.

According to the latest National Health Accounts data in Benin, the total expenditure on health, as a percentage of GDP, has been on a downward trend in the last six years. In 2006, expenditures went from 4.8 percent of GDP, to 4.3 percent in 2009 and 4.1 percent in 2010.

External resources for health, such as donors, accounted for 35.9 percent of the total health expenditures in 2010, compared to 24.4 percent in 2008 and 16.5 percent in 2003. Total public versus private expenditures on health is nearly even, with private spending at 50.5 percent. Out-of-pocket spending in Benin accounts for 46.8 percent of total health expenditures, 92.7 percent of which are made in the private sector (Figure 4).

Figure 4: Out-of-Pocket Expenditures as a Percentage of Total Health Expenditures in

Benin

Source: World Bank Databank, Trading Economies http://apps.who.int/nha/database/StandardReport.aspx?ID=REP_WEB_MINI_TEMPLATE_WEB_VERSION&COUNTRYKEY=84521 http://www.tradingeconomics.com/benin/out-of-pocket-health-expenditure-percent-of-total-expenditure-on-health-wb-data.html

Figure 5: Evolution of the Structure of Health Financing in Benin from 2003–2008*

Source: National Health Accounts 2008

*Translation: ―Reste du monde‖ (outside donors), ―Menage‖ (households), ―Governement‖ (government)

Figure 5 shows that households are the largest contributors to health spending in Benin, followed by the government and outside donors. The contribution of households to health expenditures went from 52.1 percent (National Health Accounts [NHA] 2003) to 44 percent (NHA 2008);

government contribution to health expenditures has fluctuated between 30 percent and 28 percent in the same time period. While the contribution from households between 2003 and 2008 decreased by nearly 16 percent, the percentage of income of households being spent on health only slightly decreased, from 69.4 percent (in 2003) to 67 percent (in 2008). In a context where

37 percent of the population lives on $1.50 per day, this situation constitutes a heavy burden on households, exposing a large group of the population to catastrophic health spending.

1.5 DONOR ENVIRONMENT

International donors play a significant role in Benin‘s health sector. Investment from donor outside sources nearly doubled, from 17 percent of total health funding in 2000 to 35 percent in

2010, a reality that has been accompanied by a relative decline in the national budget allocation to the health sector. The collective investment of U.S. government agencies under the GHI/Benin partnership to improve health in Benin in FY 2010 —the latest year data were available—was nearly $34 million, with USAID managing over 90 percent of this amount. The Benin health sector has existing bilateral partnerships with foreign national governments (Swiss, Dutch, French); multilateral corporations (World Bank, African Development Bank, World Health

Organization [WHO], United Nations Development Programme [UNDP]); and NGOs

(Association Française des Volontaires de la Paix, Peace Corps, Care International), as well as with U.S. agencies such as the Department of State, the Department of Agriculture, and the

Centers for Disease Control.

20 000 000 000

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2003 2004 2005 2006 2007 2008

Reste du Monde

Menage

Gouvernement

In the context of MCH, family planning, and community-based health insurance, the Benin health sector is working closely with USAID-funded partners such as Population Services

International (PSI), Medical Care Development International (MCDI), Jhpiego Corporation, and

University Research Corporation, LLC. PSI, branded under the name ABMS, works through a network of 50 clinics that provide family planning/reproductive health (FP/RH) and maternal, neonatal, and child health (MNCH) services. This network, Protection de la Famille (ProFam), is a clinical franchise that aims to improve FP services in the private sector with respect to quality of care and increase demand for and accessibility of FP. MCDI‘s Accelerating the

Reduction of Malaria-related Morbidity and Mortality (ARM-3) project seeks to implement malaria prevention and treatment interventions as well as strengthen the capacity of Benin‘s national health system, which complements USAID/Benin‘s MCH program and other donor-supported malaria programs. Other key donors, such as the Belgian Development Cooperation, partner with the private sector expanding upon public-private partnerships in Benin.

1.6 OVERVIEW OF REPORT

The Private Sector Assessment (PSA) report is divided into nine sections, covering various thematic areas, findings, and recommendations. The following breakdown gives a description of each section as well:

Section 2: Scope and Methodology of Assessment presents the scope of the assessment and the methodology used.

Section 3: Policy Environment discusses the enabling environment for health in Benin, touching upon aspects of national health policy, business licensing, and registration for both services and products.

Section 4: Service Provision in the Private Sector focuses on service provision in the private sector, providing an overview of facilities, providers, and associations in the private sector. This section will include information from literature reviews, DHS analysis, as well as primary data collected via field interviews.

Section 5: Pharmaceutical Supply and Products outlines the findings for the private pharmaceutical sector, from product availability and prices to distribution and supply chain management.

Section 6: Access to Finance covers an assessment of finance needs and constraints of providers, financial institutions active in the health market, and the business profile of providers in the private health sector.

Section 7: Health Insurance focuses on the potential for scaling up health financing options through the private sector.

Section 8: Recommendations repeats the recommendations found in the Executive

Summary.

Section 9: Conclusion summarizes the findings, recommendations, and goals of the PSA.

In the context of this report and assessment, the ―private health sector‖ includes a diversity of actors —NGOs that include both faith-based organizations and associations, as well as for-profit health care businesses ranging from treatment/prevention and pharmaceutical distribution, to financing and insurance. Traditional healers are not included in the assessment for practical reasons, but are certainly part of the private health sector.

2. SCOPE AND METHODOLOGY

OF ASSESSMENT

2.1 SCOPE OF WORK

USAID/Benin seeks practical strategies to strengthen collaboration between the public and formal private health sectors in Benin. For 2011–2015, USAID/Benin has set forth as a strategic priority the strengthening of private sector involvement to improve health outcomes in Benin. To that extent, in mid-2012 USAID/Benin commissioned the SHOPS project to undertake an assessment of the private health sector in Benin to assist USAID and other stakeholders with developing a strategy for further engaging the private sector. The strategy will complement and augment current efforts within the public and private sectors with a focus on FP, MCH, urban populations (particularly the urban poor), and existing service provider networks.

The scope of the assessment was as follows:

1. Determine the size, scope, and scale of private sector health care providers in Benin.

Identify the location and density of private sector facilities and the services they offer, especially those related to FP and MCH, as well as the supply and demand for private sector provision of health products and services in these key areas. Given budgetary and time constraints, the cadre of traditional healers in Benin was excluded from the scope of the assessment.

2. Assess the policy and regulatory environment for private provision of health products and services, particularly looking at how the public sector can steward and supervise the private sector in normalizing and aligning national health strategy and goals.

3. Assess business and financing needs of the private health sector in order to better ensure viability of facilities as businesses, with an emphasis on ProFam and AMCES facilities. Examine the extent to which access to credit could improve quality of care or expand service provision, and address training needs in business management.

4. Identify synergies with already existing USAID field support activities focused on improving health outcomes in Benin.

5. Identify opportunities to increase access to private sector health financing options by examining current initiatives.

The complete scope of work can be found in Annex A.

2.2 METHODOLOGY

The private sector health assessment took place in a four-step process: finalize a plan of action, conduct a general background literature review and research, conduct an in-country assessment, and write a report and disseminate information. Step 1 began in August 2012 with initial drafting of the scope of work, and step 4 ended in January 2012 with finalization of the first draft of the assessment report. The team that carried out the assessment consisted of three international private sector specialists, three Beninese specialists with expertise in both the private and public health sector, and two support personnel from the SHOPS team located in Bethesda, Maryland.

Step 1: Finalize plan of action. SHOPS worked with USAID/Benin to finalize the detailed plan of action, including the scope of the assessment, agreement on key survey questions, and schedule and time frame. This was established through email correspondence and several phone teleconferences throughout July and August 2012. The finalized scope of work can be found in

Annex A.

Step 2: Conduct general background literature review and research. SHOPS headquarters staff conducted background research using secondary research sources, secondary data analysis of

DHS, NHA, and other sources, in order to form a clear picture of the demand for health services in Benin. Interviews conducted later during the in-country visit phase yielded data that were subsequently added to the data collected in step 2. SHOPS used this background research to inform team members of the state of the private health sector in Benin, including, but not limited to, FP coverage and uptake, public and private sector health expenditures, and access to finance for the private health sector.

Step 3: Conduct in-country assessment. SHOPS sent a four-person team to Benin to conduct a three-week assessment. The team worked hand in hand with three local Beninese counterparts, a private health sector expert, a public health sector expert, and a banking sector specialist, while in the field to help facilitate the assessment. The following components were included in the team‘s assessment methodology:

Stakeholder Meetings: The team held meetings with key decision makers such as the MOH, USAID, and representatives of private sector entities in order to clarify expectations and explain the scope of the assessment; receive guidance and feedback, and reshape the scope of the assessment, as necessary; collect and analyze primary data; assess private sector capacity;

and further build support and buy-in to SHOPS work.

Key Informant Interviews: SHOPS team members conducted qualitative, in-depth interviews with key stakeholders and partners. Key informants included the following:

USAID/Benin staff

Implementing partners (contractors and cooperating agencies) working on private sector initiatives, specifically PSI and MCDI/ARM-3

USAID/Washington staff from the Population Office

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