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Fees-for-services, cost recovery, and equity in a district of Burkina Faso operating the Bamako Initiative. [Prestation de services, couverture des coûts et équité dans une région au Burkina-Faso exploitant l'Initiative de Bamako]
Bulletin of the World Health Organization. 2003 Jul; 81(7):532-538.Objective: To gauge the effects of operating the Bamako Initiative in Kongoussi district, Burkina Faso. Methods: Qualitative and quasi-experimental quantitative methodologies were used. Findings: Following the introduction of fees-for-services in July 1997, the number of consultations for curative care fell over a period of three years by an average of 15.4% at ‘‘case’’ health centres but increased by 30.5% at ‘‘control’’ health centres. Moreover, although the operational results for essential drugs depots were not known, expenditure increased on average 2.7 times more than income and did not keep pace with the decline in the utilization of services. Persons in charge of the management committees had difficulties in releasing funds to ensure access to care for the poor. Conclusion: The introduction of fees-for-services had an adverse effect on service utilization. The study district is in a position to bear the financial cost of taking care of the poor and the community is able to identify such people. Incentivesmust be introduced by the state and be swiftly applied so that the communities agree to a more equitable system and thereby allow access to care for those excluded from services because they are unable to pay. (author's)
Lancet. 1989 Jan 21; 1(8630):162.This letter was written in defense of a November 19, 1988 editorial discussing the Bamako Initiative. The writer, who works for UNICEF, has been working, with WHO, on the Initiative for the past year. In addition, he taught and practiced pediatrics in Ghana for 25 years. He claims the idea of "free" health services has undermined traditional African practice and confused the debate about fairness and community responsibility. UNICEF and WHO feel that increased community involvement and contribution to costs will strengthen Primary Health Care and maternal and child health systems. Acknowledged difficulties of the program, such as equity, management, foreign currency, and drug orientation are being addressed. Research and experience in community financing for health in Africa is felt to provide a solid basis for proceeding with the Bamako Initiative.