In the early 1980s, community-based funding was one of the mechanisms used to implement the policy of primary health care. Following the health reforms of the 1980s, however, the most notable change was the introduction and expansion of systems of payment of user fees (1), with sub-Saharan Africa being the area where they were probably most widely introduced (2). The economic problems facing African countries in the 1980s had adverse consequences for the health of their populations and these countries experienced difficulty in implementing the policy of primary health care. In 1987, WHO and UNICEF therefore drew up a proposal to relaunch this policy and to reduce infant and maternal mortality. This proposal, called the Bamako Initiative, was adopted in 1988 by Health Ministers of the WHO African Region. The initiative differs from the national policy of user fees, whose main objective is to generate income (3), in that its introduction should improve the quality of service and ensure equity in access to care. In practical terms the initiative may be described as follows. A stock of essential generic drugs is provided by donors to the dispensary management committee (composed of representatives of the population). The drugs must then be sold to users at a profit. This profit, in addition to payments by users for consultations (direct payment = user fees), serves to buy back the initial stock of drugs, and to improve access to care and quality of service (staff incentives, building repairs, etc).
Opinion remains divided on the impact of the introduction of user fees on the accessibility of services, particularly among the very poor (4), and it bas been the subject of much debate for more than 15 years. However, there can be no doubt that user fees are a financial barrier for poor people who wish to use health services (5). Studies in Ghana, Kenya, Lesotho, Uganda and Zambia (5-8) show that introduction of user fees reduced service utilization, a finding that is also borne out by the cross-sectional survey conducted by the World Bank in 37 countries of sub-Saharan Africa (9). One of the few longitudinal studies, carried out in Zaire, showed a 40% decrease in service utilization for the period 1987-91, of which 18-32% was due to the cost of services (10).
To date, there have been only two reports that introduction of fees-for-services had a positive impact on service utilization. The first, in Cameroon (11), showed that with an improvement in the quality of care, introduction of such fees went hand-in-hand with an increase in service utilization, with the increase being proportionally larger for the poor rather than the rich. The second study, conducted in Niger, showed that establishment of a user fee system (local tax + low patient contribution), accompanied by measures to improve quality (medicines) and exemptions (with a proper definition of the sector of the population concerned), increased attendance at a health centre by poor people (12). Commentaries on these reports (1, 13) express doubt whether the projects concerned can be repeated and applied elsewhere, particularly since they benefited from outside specialized technical assistance, not to mention considerable external funding. However, agreement with this assessment is not unanimous, particularly among individuals in favour of a direct financial contribution by users of health care service.
It is estimated that 5-30% of the population of sub-Saharan African countries is still unable to pay for health care and as a result does not have access to it (14, 15). Furthermore, thinking on the subject has changed since the 1980s. There is no longer any talk of recovering the cost of essential drugs to ensure their accessibility, as James Grant, the Executive Director of UNICEF had in mind in 1987 when he announced the Bamako Initiative (14), but rather of sharing operating costs, which goes much further and entails a far heavier financial burden for the community. …