Community financing of health care in Africa: An evaluation of the Bamako initiative
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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ABSTRACT: This article takes up the relatively neglected issue of gender in human resources policy and planning (HRPP), with particular reference to the health sector in developing countries. Current approaches to human resources lack any reference to gender issues. Meeting the health needs of women as major users and potential beneficiaries of health services is a key international concern. This article argues that in order to do this, attention must also be paid to both equal opportunities and efficiency issues in the health sector workforce, given the highly gender segregated nature of occupations in the health sector and the potential for both gender inequity and inefficiency in the use of human resources which this poses. Taking gender seriously in HRPP entails developing appropriate methodologies for data collection, monitoring and evaluation. The paper suggests some basic ways of doing this and provides a framework for incorporating gender concerns in health reform processes. 1. Context -why consider gender in human resource policy and planning? In view of the importance of human resources planning to delivering the health sector reform agenda, the lack of attention to its gender dimensions requires rectifying. This is a preliminary attempt to address the issue and provide some guidance in how to make human resources policy and planning more gender aware. It is based mainly on secondary sources and focuses particularly on nursing. In general, most work on gender and health care has focused on demand side issues. These include in particular the wide range of barriers to institutional access experienced by women users (1,2) , gender discrimination in health care expenditure affecting women and girls, the exclusive concentration on women's reproductive health to the neglect of other dimensions of their health (3) , and the impact of cost recovery programmes on women and children (4) . There has been much less emphasis on gender in relation to the production of health care (5,6) . Yet there is often a clear gender dimension to both formal and informal care systems. Much of the non-institutional care of the sick is carried out by female household and community members (7) . Similarly, formal health systems tend to be gender differentiated in terms of their divisions of labour and associated hierarchies, with women frequently concentrated in specific segments of the health care labour force. They are less likely than men to be in senior professional, managerial and policy making roles (5,8,9) . A study of human resources in Zimbabwe notes that women's formal sector employment is mainly in the service sector. In health, women outnumber men as employees, holding 57.4% of the total employment (10) . It also notes that women are concentrated at the lower end of the hierarchy and salary grades.