In a precarious balance between generosity and wrongdoing, the free provision of care for the underprivileged exposes medical equity funds to risks of corruption. Launched in 2004, the equity fund allows the most disadvantaged to benefit from health care services. But few users of health services are aware of the existence of this equity fund, which allows for corruption practices to go unreported.
The equity fund at the service of solidarity
“The equity fund is drawn from the fund “Fandraisana Anjara No Mba Entiko” (Fanome), translated into French as Financing for Non-stop Supply of Medicines. This fund ensures coverage for medications for the needy,” Solonirina Ranoroarisoa, a dispenser at the Level II Health Center (CSB II) of Sabotsy Namehana, explains.
If we go back a bit in history, the free provision of healthcare and access to medications were established as fundamental rights after independence. It is only by decree N°2003/1040 of October 14, 2003, followed by interministerial orders N°5228/2004 dated March 11, 2004, implementing the said decree, that the procedures for conducting the Fanome within public health facilities were established.
The Fanome is a community financing mechanism applied within basic health centers (CSBII). An estimated proportion of 3/135 of the Fanome’s revenues, collected from the sale of medicines at CSB II, is transferred to the equity fund to ensure support for the needy. The solidarity fund is based on a spirit of mutual aid and solidarity: those who have the financial means support the most vulnerable individuals. But do these individuals understand how this mechanism works?
A health benefit unknown to its beneficiaries
September 2023, we are in Sabotsy Namehana, a suburban commune nestled in the district of Avaradrano. This locality located about fifteen kilometers from Antananarivo is home to nearly 70,000 inhabitants spread in 17 fokontany including that of Atsinanantsena.
Pétroline Ralisoa is registered on the list of beneficiaries of the Atsinanantsena equity fund. When questioned, Ralisoa did not hide her surprise: “I am not aware that I am on a list of recipients of a health benefit from the CSB II. This is the first time I hear about it.”
Pétroline Ralisoa is not an isolated case. Among the 10 people recorded among the beneficiaries, only one was able to fully understand and benefit from her rights regarding the fund in question. This is Martine Razanajay, 72 years old, who suffers from an artery disease and a chronic vision impairment. “I receive free care and free medication from the CSB II, and I must admit that it has been a great help for a vulnerable person like me,” she expresses.
A little further along in the municipality of Bemasoandro Itaosy, Voahirana Rasolomampionona and Berthine Rasoarimalala live respectively in the neighborhoods of Anosimasina and Ampasika. They assure that they have only rarely gone to the CSB II and are not aware of the existence of this solidarity mechanism for health care benefits.
A public aid kept silent
In principle, it is the fokontany that is responsible for establishing the list of beneficiaries of the equity fund. However, it is at the level of the fokontany themselves where confusion and lack of transparency begin. In Atsinanantsena in the municipality of Sabotsy Namehana, among the 6,918 inhabitants of the fokontany, 170 are classified as underprivileged and therefore, beneficiaries of aid from Fanome. The existence of the equity fund is not officially communicated by the fokontany office. The fokontany chief defends his position: “If we made the existence of the equity funds public, many will apply to be beneficiaries, while the benefit would not cover much. People will continuously return to the CSB II, just to take advantage of this opportunity. »
At CSB II, the equity fund managers emphasize a maintenance discourse to explain the low dissemination of this mechanism among users. Rakoto, a pseudonym to protect his anonymity, is a member of the health staff at the CSB II of Sabotsy Namehana. He explains: “How are we going to manage a crowd of people who show up at the CSBII, claiming to be in need when the amount allowed by the equity fund wouldn’t even cover a third of the residents in our fokontany?”
However, if the majority of legitimate beneficiaries are not informed about the existence of this equity fund, some are indeed well-informed. With funding deemed lesser and the maintenance of order to justify the lack of communication, in reality, how are the individuals who can benefit from this equity fund identified?
Being on the list of beneficiaries is not always obvious…
The criteria for identifying disadvantaged families vary from one locality to another. Robertine Rakatroarilala, administrative secretary within the municipality of Bemasoandro, explains the principle by which the beneficiaries were selected for her municipality: “Elderly people with low income and a modest standard of living, widows with more than four dependent children, orphans, and people with disabilities may be included in the list of the needy. » To identify these targets, Rakatroarilala explains that the municipality of Bemasoandro uses questionnaires sent to the residents in the fokontany.
In Sabotsy Namehana, the method is different in the fokontany of Atsinanantsena: the head of the fokontany establishes the list of beneficiaries. But this list as well as the selection criteria are not made public, so that people who could benefit from assistance, such as free health services, are not systematically informed. The head of the fokontany of Atsinanantsena defends himself: “If I had bad intentions, I would provide my loved ones with free care by putting them on the list.”
Fokontany, municipalities, health centers: who does what?
Three entities are involved in the equity fund mechanism. Firstly, the fokontany that produce the list of beneficiary persons. Secondly, the municipalities that validate the list and send it to the CSBs. Finally, the CSBs execute the healthcare service and provide medication.
But collaboration is not always smooth. For example, the head of the fokontany of Anosimasina, in Bemasoandro, accuses the municipality of not raising awareness among residents about the equity fund issue. Joël Claire Rasoaniaina, head of the fokontany Anosimasina explains: “There is no communication regarding the equity funds transferred by the municipality to the fokontany. Moreover, it is the fokontany that contributes to the purchase of medicines for vulnerable individuals.”
At the municipal office of Bemasoandro, Robertine Rakatroarilala confides: “The municipality cannot really determine the list of needy people without the collaboration of the fokontany. But while they are supposed to provide us with these lists, it is we, within the municipality, who are forced to request them in order to organize the various aid distributions for the most disadvantaged.” At the level of health centers, another issue arises. Rakoto of CSBII highlights : “Our mission is to save lives. Thus, the fund is used, for example, to cover emergency cases, even if the individuals are not on the list validated by the municipality.”
Misunderstandings, lack of communication, and medical emergencies then burden the management of equity funds. How can we then ensure the transparency and eligibility of the allocation of expenditures from these funds?
What about transparency in the management of the equity fund?
Théophile Rakotonanahary, secretary general and member of the management committee of the Fanome fund within the municipality of Sabotsy Namehana explains that the municipality has an obligation to report monthly to the Ministry of Public Health. on the transactions made on the Fanome account and on the equity funds. “In general, the planned expenses for the latter include good care for needy individuals and the fees for maintaining the bank account. It’s up t the the supervising Ministry to verify the exact correspondence of the account movements,” he tells us.
To date, the Ministry of Public Health has not responded to our interview requests and follow-ups made over the past two months, in order to gather the views of various officials on the transparency of the management of this equity fund mechanism. With nearly 20 years of existence, the equity fund remains unclear for the majority of its beneficiaries, as well as for those who can contribute to funding this mutual aid fund.
By : Antsamalala Felana Fitiavana, Avotra Ravalijaona, Onjalalaina Ranaivomanana, Johnattan Rahaga
