Local cost sharing in Bamako Initiative systems in Benin and Guinea: assuring the financial viability of primary health care

The fourth in a series of five, this article presents and analyses data on cost recovery and community cost-sharing, two key aspects of the Bamako Initiative which have been implemented in Benin and Guinea since 1986. The data come from approximately 400 health centres and result from the six-monthly monitoring sessions conducted from 1989 to 1993. Community involvement in the financing of local operating costs in the two national scale programmes is also described. In Benin and Guinea, a user fee system generates the community financed revenue with the aim of covering local operating costs including drugs. Health worker salaries remain the responsibility of the government and donor funding covers vaccine and investment costs. Village health committees manage and control resources and revenue. The community is also involved in decision making, strategy definition and quality control. In Benin in 1993, community financing revenue amounted to about US$0.6 per capita per year and generally covered all local recurrent non salary costs except vaccines and left a surplus. Although total costs and revenues were slightly lower in Guinea for the same period, over-all user fee revenue (around US$0.3 per capita per year) covered local recurrent costs (not including salaries or vaccines). A comparison of costs and revenue between regions and individual health centres revealed important differences in cost recovery ratios. In Benin, some centres recovered more than twice the local costs targeted for community financing. Twenty-five per cent of centres in Guinea did not manage to cover their designated local recurrent costs. The longitudinal analysis showed that the level of cost recovery remained stable over time even as preventive care (and especially EPI) coverage rose significantly. To better understand the most important characteristics affecting cost recovery levels, best performing health centres in terms of cost-recovery levels in 1993 were compared to worst performing centres. This analysis showed that the size of the target population of the health centre is a key determinant of cost-recovery in both countries. In addition, in Guinea the utilization of curative care linked to geographical access and in Benin the average revenue per case linked to the number of deliveries proved to be additional factors of importance. In best performing centres, financial viability improved over time in both countries between 1990 and 1993. Finally, the implications of these conclusions for the planning of health centre revitalization in West Africa are discussed.     

Implementation of the Bamako Initiative: strategies in Benin and Guinea

Two West African countries, Benin and Guinea, have been reorganizing their peripheral health systems since 1986, with the goal of improving access to primary health care (PHC). A comprehensive approach evolve, based on improving effectiveness, optimizing efficiency, ensuring financial variability and promoting equity. These strategies were launched as the Bamako Initiative by the World Health Organization's Regional Assembly in 1987. This is the first in a series of five articles on the Bamako Initiative in Benin and Guinea. The strategies implemented in these two countries are discussed. Subsequent articles discuss the improved health indicators, impact on service costs efficiency, and community empowerment through local cost recovery and equity implications. The health center is the basis for a revitalized primary care system. From here, an integrated minimum health care package is readily accessible to meet basic community health needs. Through the Bamako Initiative program, drugs and other essential resources are always available, regular contract between the community health service providers and communities has increased, and the quality of care has improved while also becoming more efficient. Community health resources are managed locally through joint microplanning and monitoring, involving health personnel and village committees. Community ownership, fostered by local budgeting and decision making, is an essential pillar for the success of the system.     

Health seeking behaviour and household health expenditures in Benin and Guinea: the equity implications of the Bamako Initiative

Curative and preventive care utilization in Bamako Initiative health centres in Guinea and Benin increased significantly. Service based data and household survey results are compared and interpreted to evaluate the equity aspects of the Bamako Initiative programmes in these settings. Improvements in the use of preventive services are shared by the richer and poorer groups of the population. Inequities are more apparent regarding curative area. An important part of the population is not using Bamako Initiative Health Centres for financial reasons. However, the poor were found to use these Health Centres relatively more than richer socio-economic groups. Challenges of the future are identified and recommendations made as to how to tackle the problem of true indigence.     

Guinea worm control: testing the efficacy of health education in primary care

Health education has been advocated as a major foundation for primary health care. However, the value of this approach is yet to be fully proven. An experimental PHC programme in ten Nigerian farm hamlets using methods such as community organization, participatory training and village meetings, put health education to the test. Significant short term improvements in community health knowledge resulted after training of a village health worker from each hamlet. Positive intermediate results in water sanitation behaviours were later observed. Three years after initial intervention, long term health outcomes included the reduction in prevalence of guinea worm, a locally endemic water borne disease. The programme also encountered certain organizational and technological issues. For example, integration with existing health care systems and local well construction capabilities surfaced as problems. Consequently efforts are currently underway to expand research into these areas.     

The need for integrated primary health care to enhance the effectiveness of health services

With the increasing prevalence of chronic illnesses and health compromising behaviours, health care expenditure is escalating with the expansion of hospital services. Integrated primary health care would enhance the cost effectiveness of health care delivery. Recent studies on primary care health services research in Hong Kong indicated that there is a high level of inappropriate utilisation of hospital emergency services, a high prevalence of youth health risk behaviours particularly mental health which would lead to a heavy burden on health services in the future. The community based rehabilitation provided a better quality of life for chronic illness patients, better drug compliance for chronic illness patients in family practice, and a disproportionate amount of budget is spent on law reinforcement and treatment for drug abuse rather than on prevention and education. The findings strongly indicate the need to have a strong primary health care team with well trained family physicians and trained health professionals as primary care practitioners to provide services on health promotion; curative; rehabilitation and supporting services; supporting self help activities of individuals, families and groups. This would minimize compartmentalisation in health care delivery, and is also a cost effective way of providing high quality holistic and comprehensive care that meets the needs of the majority of the population.     

The Sandyford Initiative: creating added value to health and health care

The Sandyford Initiative in Glasgow brings together Family Planning, Genitourinary Medicine and the Centre for Women's Health in a new partnership which aims to provide integrated health and social care in a manner which reflects a social model of health. The Steve Retson Project for Gay Men's Sexual Health is also situated within the Sandyford, providing clinical services within the context of a social model of health. The Initiative is managed by the Greater Glasgow Primary Care NHS Trust but has been developed as a result of joint working between three main services, Greater Glasgow Health Board, Glasgow City Council and a number of voluntary organisations. By working to a social model of health, the intention is to ensure that the detection and management of health problems takes into account the social and economic determinants of health and that the provision and practice of health care reflects the social needs of the user. As such the Initiative is expected to make a significant contribution to the sexual health of men and women and the general and reproductive health of women in the Greater Glasgow area and beyond. The core of the Initiative is housed in premises tailored to the needs of the services and their users although satellite services are being planned. In addition to the core clinical and non-clinical care there are services designed to respond to the needs of specific groups such as young people, black and ethnic minority communities and disabled people, in order to improve access and uptake by previously marginalised groups. It is recognised that often the relationship between health and social service providers and their users becomes strained. Implementation of the Sandyford Initiative is intended to inspire confidence and contribute effectively to improving health and managing complex health problems.     

The origins of primary health care and selective primary health care

I present a historical study of the role played by the World Health Organization and UNICEF in the emergence and diffusion of the concept of primary health care during the late 1970s and early 1980s. I have analyzed these organizations' political context, their leaders, the methodologies and technologies associated with the primary health care perspective, and the debates on the meaning of primary health care. These debates led to the development of an alternative, more restricted approach, known as selective primary health care. My study examined library and archival sources; I cite examples from Latin America.     

Costs and financing of improvements in the quality of maternal health services through the Bamako Initiative in Nigeria

This paper reports on a study to assess the quality of maternal health care in public health facilities in Nigeria and to identify the resource implications of making the necessary quality improvements. Drawing upon unifying themes from quality assurance, basic microeconomics and the Bamako Initiative, locally defined norms were used to estimate resource requirements for improving the quality of maternal health care. Wide gaps existed between what is required (the norm) and what was available in terms of fixed and variable resources required for the delivery of maternal health services in public facilities implementing the Bamako Initiative in the Local Government Areas studied. Given such constraints, it was highly unlikely that technically acceptable standards of care could be met without additional resource inputs to meet the norm. This is part of the cost of doing business and merits serious policy dialogue. Revenue generation from health services was poor and appeared to be more related to inadequate supply of essential drugs and consumables than to the use of uneconomic fee scales. It is likely that user fees will be necessary to supplement scarce government budgets, especially to fund the most critical variable inputs associated with quality improvements. However, any user fee system, especially one that raises fees to patients, will have to be accompanied by immediate and visible quality improvements. Without such quality improvements, cost recovery will result in even lower utilization and attempts to generate new revenues are unlikely to succeed.     

The effectiveness of contracting-out primary health care services in developing countries: a review of the evidence

The purpose of this study is to review the research literature on the effectiveness of contracting-out of primary health care services and its impact on both programme and health systems performance in low- and middle-income countries. Due to the heightened interest in improving accountability relationships in the health sector and in rapidly scaling up priority interventions, there is an increasing amount of interest in and experimentation with contracting-out. Overall, while the review of the selected studies suggests that contracting-out has in many cases improved access to services, the effects on other performance dimensions such as equity, quality and efficiency are often unknown. Moreover, little is known about the system-wide effects of contracting-out, which could be either positive or negative. Although the study results leave open the question of how contracting-out can be used as a policy tool to improve overall health system performance, the results indicate that the context in which contracting-out is implemented and the design features of the interventions are likely to greatly influence the chances for success.     

An analysis of the effectiveness of Spanish primary health care teams

One of the main objectives of the managers of public health systems in most developed countries is the modernisation of public services through managerial reforms as a way of resolving the traditional inefficiency of this sector. The objective of this article is to observe how the introduction of one tool traditionally used in the private sector, the organisation of work through teams, can contribute to improved performance in public health services. The study was conducted in the primary health care teams of Navarre, an autonomous region of Spain, where a new model of primary health care, based on teamwork was implanted. We analyse the relationship between team characteristics, team members' individual features and team performance from a stakeholder approach. We can conclude that teams are a form of organisational design useful for improving performance in primary health care because insofar as they function properly, they achieve greater degrees of job satisfaction for the employees, greater perceived quality by the users and greater efficiency for the Administration.     

Memisa and the development of a health care system in Benin

The organization Memisa Medicus Mundi puts the emphasis of its activities in third world countries such as Benin on the structural development of a solid health care system. This policy is being implemented through close cooperation with local partners. This strategy allows for interventions which do not upset the existing social relationships and which do not have a negative influence on the performance of health care institutions. The general health of the Benin population is poor: life expectation at birth is 47 years and 24% of children under the age of 5 suffer from undernutrition. With financial and technical support of Memisa, three hospitals have been set up in North Benin which later on were turned over to the Benin physicians. In addition, a system of medical insurance was started up, based on the traditional forms of mutual solidarity. Progress may be accelerated by coordinating the aid of non-governmental organizations in Benin; to this purpose, Memisa has aided in founding AMCES (Association des Oeuvres Médicales Privées Confessionnelles et Sociales--Private, Confessional and Social Health Care Association), a union that serves as a discussion partner for the government and helps supplying the country with medicaments.     

The opportunities and effectiveness of the health promoting primary school in improving child health--a review of the claims and evidence.

School health programs have been part of schooling for most of this century. The health promoting school is a recently developed concept which seeks to provide a multifaceted approach to school health. Will it provide a better frame-work to assist schools address the health issues of their students? This paper examines the development of the health promoting school and identifies its structural components. It reviews the claims and evidence which have emerged from the school health research literature which focus on primary schools. Findings indicate health gains for primary school students are difficult to assess, and will most likely occur if a well-designed program is implemented which links the curriculum with other health promoting school actions, contains substantial professional development for teachers and is underpinned by a theoretical model. The paper concludes by discussing how improvements can be made in more accurately assessing the effectiveness of the health promoting primary school in improving school health.     

The effects of preconception interventions on improving reproductive health and pregnancy outcomes in primary care: A systematic review

Background: Reproductive health and pregnancy outcomes may be improved if the reproductive risk assessment is moved from the antenatal to the preconception period. Primary care has been highlighted as an ideal setting to offer preconception assessment, yet the effectiveness in this setting is still unclear.

Objectives: To evaluate the effectiveness of preconception interventions on improving reproductive health and pregnancy outcomes in primary care.

Methods: MEDLINE, CINAHL, EMBASE and PsycINFO databases were searched from July 1999 to the end of July 2015. Only interventional studies with a comparator were included, analysed and appraised systematically, taking into consideration the similarities and differences of the participants, the nature of interventions and settings.

Results: Eight randomized controlled trials were eligible. Preconception interventions involved multifactorial or single reproductive health risk assessment, education and counselling and the intensity ranged from brief, involving a single session within a day to intensive, involving more than one session over several weeks. Five studies recruited women planning a pregnancy. Four studies involved multifactorial risks interventions; two were brief and the others were intensive. Four studies involved single risk intervention, addressing folate or alcohol. There was some evidence that both multifactorial and single risk interventions improved maternal knowledge; self-efficacy and health locus of control; and risk behaviour, irrespective of whether brief or intensive. There was no evidence to support reduced adverse pregnancy outcomes. One study reported no undue anxiety. The quality of the studies was moderate to poor.

Conclusion: The evidence from eligible studies is limited to inform future practice in primary care. Nevertheless, this review has highlighted that women who received preconception education and counselling were more likely to have improved knowledge, self-efficacy and health locus of control and risk behaviour. More studies are needed to evaluate the effects on adverse pregnancy outcomes.