Goal 7: accountability and community participation

Whether a good is free or whether it is charged for has major implications for the way the consumer views it. If a good such as health care is free, but not good quality, the consumer may not feel motivated or enabled to complain and demand better services.

One major contention of the Bamako Initiative is that the community takes more interest in public health services when they contribute financially to these services. Therefore cost sharing would lead to community involvement, which improves quality of care and makes health services more responsive to community needs.

Community involvement has been recorded in many ways, for example through community representation on health boards, election of representatives by the community, and patient feedback mechanisms. See the World Bank's background paper on the Bamako Initiative in West Africa. But because these mechanisms were often linked to the implementation of the Bamako Initiative, it is difficult to say whether they developed because of user fees or because community participation was being promoted generally. It has, however, been reported that health management committees met less frequently or not at all, and that central government was taking a larger role in the management of health units, after the discontinuation of cost sharing in Uganda.