The equity impacts of community financing initiatives in Africa

Access to healthcare is closely linked to health service financing in developing countries. The Bamako Initiative for community or user financing of healthcare in Africa is surrounded by debate over its impact on equity within and between sections of society. How does the design of such schemes affect equity of access to healthcare?

Researchers from the South African University of Witwatersrand and the London School of Hygiene and Tropical Medicine investigated the equity impacts of community financing initiatives in Benin, Kenya and Zambia. Are there improvements in relative or absolute affordability? How far do equity issues influence decision making on financing activities?

The investigation centred on three linked principles of equity:

• payment on the basis of ability to pay
• equal opportunity of use for equal need
• effective representation of all community interests in decision-making.

The researchers found that none of the health schemes in the three countries incorporate the first or third principle, although there are limited gains against the second. The definition and understanding of equity that guide the implementation of health sector reforms do not necessarily prioritise access for the poorest and most marginalised people. The study found improved equality of opportunity between rural and urban populations for basic primary care. But for higher-level services they found no change or reduced opportunity between rural and urban populations and within rural communities.

Other findings of the study include:

• Access to quality curative care has improved in Benin and Kenya thanks to comparatively low indirect costs and increased availability of drugs.
• Vulnerable groups in these two countries also benefit from cross-subsidisation between preventative care and health promotion.
• However, with the possible exception of Benin, the poorest and most marginalised groups gain less than others from improved services. No country has effective mechanisms to protect these groups from the burden of payment.
• Community structures rarely reflect the views of the wider population. The poor have no effective voice in decision-making processes.
• The focus on primary health means that care for more serious illnesses is still very expensive.
• Equity gains in Kenya are compromised by the unsustainability of pharmacies and networks and by wealth inequalities between communities. By contrast, provisions for geographical re-allocation of resources in Zambia may overcome inter-community differences.

The researchers drew the following policy-related conclusions from the study:

• Equity is a minor goal in all the schemes. The objectives that they embody are at odds with the principles outlined above.
• Fee changes designed to promote partnership with the community and to raise revenue in Zambia conflict with the equity goals of the health reforms.
• The schemes in Benin and Kenya aim to improve services to population groups defined as disadvantaged or vulnerable to illness, rather than to improve access and participation for the poorest.
• The scheme in Benin has been more successful than those in Kenya and Zambia in reaching the goals that guided its implementation.
• Evaluation of equity gains depends greatly on the evaluator’s chosen understanding of the term.

Source(s):
‘The equity impacts of community financing activities in three African countries’ by L. Gilson et al., International Journal of Health Planning and Management 15 (2000)

Funded by: UNICEF; WHO TDR

id21 Research Highlight: 14 February 2002

Further Information:
Lucy Gilson
Centre for Health Policy
University of Witwatersrand
PO Box 1038
Johannesburg 2000
South Africa

Tel: +27 11 489 9941
Fax: +27 11 489 9900
Contact the contributor: lucyg@mail.saimr.wits.ac.za

University of the Witwatersrand, South Africa

Sally Lake
Health Policy Unit
London School of Hygiene and Tropical Medicine
Keppel Street
London WC1E 7HT
UK

Tel: +44 (0)20 7927 2262
Fax: + 44 (0)20 7637 5391
Contact the contributor: sally.lake@lshtm.ac.uk

London School of Hygiene and Tropical Medicine, UK

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