Cote d'Ivoire: Free Health Care Window Highlights Challenges (OneWorld.net)

DAKAR, Jun 10 (IRIN) - The Ivoirian government has extended a special period of free health care to help a population reeling from months of turmoil. But in a country where cost recovery for health services has long been the policy, an abrupt change to free care is posing challenges.

“If we are to provide quality care for the population, we must take a step back, study this and reorganize,” said Fabrice Ble, a doctor at a community health centre in Port-Bouet in the main city Abidjan.

Shortly after Alassane Ouattara took power in April 2011, he announced that public health services would be free until the end of May as a way to help people in the aftermath of widespread unrest and economic stagnation.

On 8 June, after a few days of uncertainty about this policy, the Health Ministry announced free care would be extended “until further notice”.

In recent years some countries in West Africa have made health services free for certain groups like women and under-five children, but Cote d’Ivoire has maintained health user fees; offering free care in public hospitals was for the current exceptional circumstances only. The system is not set up for free health services.

Doctors reported 20-30 times the number of patients after free care was announced. Advocates of free care say the explosion of patients indicates that cost is one of the biggest barriers to access.

But even advocates say a shift to free care is not like flicking a switch. “This is not something that changes overnight,” said Ina Bluemel, senior health coordinator with Save the Children, which is calling for universal health care.

Cote d’Ivoire would have to determine additional staff and supply requirements, reform tax and insurance systems, mobilize additional funding from the national budget and inform the public of the policy change, Save the Children says in a communique.

“Even though the temporary waiving of fees has benefited people across the country, it remains a short-term solution to a much deeper problem.”

Rob Yates, health economist with the UK government’s Department for International Development, says several "supply-side" reforms are necessary when a government removes fees, including increasing health workers' salaries and benefits, ensuring they are paid regularly and improving accountability mechanisms.

It is not clear whether the Ivoirian government is considering waiving fees for good.

Taking stock

Health officials are evaluating how the initial phase went, said Ousmane Aidara, communications officer in the Health Ministry. “We are looking at what worked and what didn’t and the public’s take on this approach. We are studying whether it should be extended again and if so for how long.”

In April, just as the heaviest fighting subsided, several aid agencies provided supplies and support to health facilities, and medicines to the central pharmacy. But emergency aid is not part of a sustainable health system.

Save the Children has welcomed the extension, saying it and other NGOs continue to meet Health Ministry officials to help develop a long-term solution to accessible health care.

Meanwhile, health workers are struggling to absorb the high number of people coming through and navigate in the new no-fee mode. Ble, the doctor in Port-Bouet, said under cost recovery the money patients pay goes into state coffers. “If now the government figures it can offer free health care to the population, fine and good. But health workers then must have all the means at their disposal to offer quality care.”

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Cote d'Ivoire: Reluctant to Return Home (OneWorld.net)

ABIDJAN, May 24 (IRIN) - While outright conflict has abated in Cote d’Ivoire’s commercial capital, Abidjan, many of the thousands of displaced people there are still too fearful to return to once conflict-ridden neighbourhoods.

Fear of men in uniform, fear of continued arms flows, and of unexploded ordnance (UXO) is keeping Abidjan residents from returning home, displaced people told IRIN.

Arms are still circulating in some neighbourhoods, residents of Abobo and Yopougon told IRIN. These neighbourhoods saw some of the heaviest fighting between President Alassane Ouattara’s Forces Republicaines de Cote d’Ivoire (FRCI), ex-President Laurent Gbagbo’s fighters, and other militia groups.

UXO has been identified by the UN Operation in Cote d’Ivoire (UNOCI) in 60 sites around the city, including near hospitals, schools, businesses and in people’s homes.

On 21 May UN Secretary-General Ban Ki-moon visited the Union of Evangelical Churches, which is sheltering 160 displaced people in Cocody, an eastern Abidjan neighbourhood. Cecile Bla, 48, fled to the shelter from Yopougon.

Bla’s home and business - she sold cosmetics - were pillaged, leaving her with nothing. She is now baking tarts for sale to support her five children.

“I lost everything… I know I need to start a new life, but that will not be before I can be guaranteed better security.” Life is slowly returning to normal in Yopougon, and the streets are filling up, but Bla’s neighbours regularly ring her with reports of armed men turning up to the compound unannounced, leaving her scared. There have been some reports of continued, sporadic aggression committed against civilians in Yopougon and Abobo, according to the UN.

Members of the FRCI still man checkpoints in Yopougon, to keep the peace; and mixed patrols of UNOCI, French Licorne forces and ex-President Laurent Gbagbo’s gendarmerie patrol the streets of the capital; but many residents still fear, rather than trust, men in uniform.

Still traumatized

Some who witnessed violence are still traumatized by it. Habiba Kante, 36, stayed in the Abobo neighbourhood amid heavy fighting before fleeing to the church shelter. She now jumps in fear every time she hears a car horn.

“It’s like reliving the war. I know I need to restart a new life and that I must return, but I can’t do that until I get a guarantee that it is safe, and that guns are no longer in circulation in the streets,” she told IRIN.

Pastor Michel Loh, who is running the church shelter, is trying to help children recover by setting up a temporary school for them. Schooling can be instrumental in the psychosocial recovery of children in conflict. Kane’s seven-year-old daughter, Aisha Diakite, may make up the school year rather than having to skip a year, said Loh.

Clearing UXO

To enable people to return home, a joint UNOCI and FRCI team is trying to clear sites of unexploded bombs, grenades and mines, according to UNOCI spokesperson Hamadoun Toure. Some 40 sites have been cleared out of a total of 60 reported thus far, though sightings continue to rise, said UNOCI’s Col Rayes Koshavsky.

The team will clear sites outside Abidjan once they have cleared the commercial capital of ordnance, said Toure.

Ban Ki-moon and local UN Refugee Agency head Jacques Franquin stressed that in the meantime, there is no hurry to return. “No one will be forced to return until they are ready,” Ban told displaced families. “Many of you have lost everything, and have witnessed terrible atrocities. You must heal so that you can try to relive a normal life.”

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