Community Financing of Health Care in Africa: An evaluation of the Bamako Initiative

Health Economics and Financing Programme, London School of Hygiene and Tropical Medicine, U.K.
Social Science & Medicine (Impact Factor: 2.56). 06/1993; 36(11):1383-1395. DOI: 10.1016/0277-9536(93)90381-D
Source: RePEc

ABSTRACT The Bamako Initiative, a controversial attempt to strengthen Primary Health Care using community financing and community participation and management was launched at a meeting of African Ministers of Health in 1987. This evaluation focuses particularly on the community financing aspects of the Initiative. Previous experiences of community financing highlight particular lessons for the development of the Initiative and issues likely to be encountered in implementation attempts. Four country case studies of the Initiative at its early stages of implementation (in June, July and August 1991) were conducted in Burundi, Guinea, Kenya, and Nigeria. Similar activities in Uganda were also studied. These were short studies of one month each and utilised methods of rapid evaluation. The studies aimed to direct implementers quickly to issues requiring attention rather than to reach overall conclusions regarding the success of the Initiative which would be premature at this stage. Price structures used by the Initiative need to consider the access of marginalised groups more than is the case at present. In addition, there is a need to ensure against over-prescription and commercialisation and to ensure that incentives for utilising most appropriate levels of care are maintained. The evidence suggests that most people do find amounts of money to pay for health services which are large in relation to their income. This is probably a tribute to extensive community support mechanisms. Nevertheless, it highlights the plight of those who fall through this safety net for whom even charges for very basic care may be prohibitive. On the other hand, it appears that in most cases, the Initiative's activities provide a service which is cheaper when all costs to the household are taken into account, than was available before. The quality of services included in the Initiative's activities in the five countries was highly variable. Success in raising substantial revenues has also been mixed. In some countries however, substantial funds have been generated and used to achieve real improvements in health services. Overall, the experiences of the five countries appear to have been highly dependent on a number of 'environmental' characteristics: a tradition or not of 'free' services; the adequacy of current resource availability and that immediately preceding the introduction of the Initiative; the existing stage and nature of decentralisation within the country; and the competition the Initiative's activities face with alternatives.

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    • "Using the Bamako approach, program managers focused resources on recruiting community health-care volunteers, organizing community supervision of their work, and providing initial essential health-care resources that communities would sustain through user fees and revolving accounts (Knippenberg et al. 1990; UNICEF 1991 and 1995). The initiative soon became controversial, however, when evaluation research revealed mixed results (McPake et al. 1993). "
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    • "For more details see, for example, Abel-Smith and Dua (2008), Moens (1990), McPake et al. (1993), Abel-Smith and Rawal (1994), Arhin (1994) and Ensor (1995). For an extensive survey of CBHIS's across developing countries, see, for example, Bennett et al. (1998). "
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    ABSTRACT: Community-based health insurance schemes attempt to bridge the gap between increasing health needs and scarce resources in poor communities as well as providing protection for the most vulnerable groups through cross-subsidization. However, these schemes are often initiated without strong empirical information that can help to benchmark cost-sharing potentials of households in the community. This study assesses the Willingness To Pay (WTP) of rural Nigerians for one aspect of the nation’s new National Social Health Insurance Scheme initiated in 2004. As a case study, the Nsukka District of Enugu State, Southeastern Nigeria is used, where a rural community social health insurance scheme is being proposed by the local authorities. The results indicate that rural households in the area have WTP of about 181 Naira or $1.5 monthly as healthcare premium for this scheme. This amount was found to be positively and significantly correlated with household educational attainment, household wealth, household size and the level of trust households have in the management of the proposed scheme.
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    • "The cost for a caesarean section is as much as 30,000 CFA [15] but antenatal care and vaccination are provided free of charge. In 1992–1993, Burkina Faso implemented the Bamako Initiative, a health sector reform in Sub-Saharan Africa that included several strategies, one of which was the implementation of user charges to increase the availability of essential drugs and other health care services [16] [17] [18]. Before the introduction of user fee, annual per capita contacts to the health facility were about 0.31 [19]. "
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    ABSTRACT: Objective To quantify the impact of community-based health insurance (CBI) on utilization of health care services in rural Burkina Faso.Methods Propensity score matching was used to minimise the observed baseline differences in the characteristics of insured and uninsured groups such that the observed difference in healthcare utilisation could generally be attributed to the CBI.Results Compared with those who were not enrolled in the CBI, the overall increase in outpatient visits given illness in the insured group was about 40% higher, while the differential effect on utilization of inpatient care between insured and non-insured groups was insignificant. Not only were the very poor less likely to enroll in CBI, but even once insured, they were less likely to utilize health services compared to their wealthier counterparts.Conclusions The overall effect of CBI on health care utilization is significant and positive but the benefit of CBI is not equally enjoyed by all socioeconomic groups. The policy implications are: (a) there is a need to subsidize the premium to favor the enrolment of the very poor; and (b) various measures need to be placed in order to maximize the population's capacity to enjoy the benefits of insurance once insured.
    Health Policy 05/2009; 90(2-3):214-222. DOI:10.1016/j.healthpol.2008.09.015 · 1.73 Impact Factor
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