Voir page 1036 le resume en francais. En la pagina 1037 figura un resumen en espanol.
One of the consequences of the disruption following the conflict in Uganda was that the salaries of health workers were often irregularly paid; indeed, delays of over six months were common (1). Furthermore, the salaries were very, low, e.g. US$ 50 for a physician, US$ 30 for a medical assistant, and US$ 10 for a nurse. These workers therefore sought additional sources of income and could not spend enough time on health care. The situation was particularly pronounced in remote areas, where opportunities for supplementary employment were comparatively limited. This resulted in the suboptimal utilization of health services: attendance rates ranged from 0.1 to 0.3 visits per head per year (1). Because of these circumstances a user-fee system was introduced in Kabarole District as a staff incentive mechanism, although there was an underlying concern that this step might actually reduce utilization further. In Ghana, for example, a significant drop in the utilization of health facilities was reported in 1985 after user fees were substantially increased (2). In Kenya, the number of male visitors to sexually transmitted disease clinics in the public sector fell by 40% after user charges for outpatient clinics were introduced in 1989 (3). Studies in many other developing countries have shown comparable effects (4-8). Similar conclusions have been drawn from studies in industrialized countries (9-11).
The introduction of user fees usually involves a top-down approach in which government introduces fees for health services. Few examples have been reported where cost sharing began as a community initiative and resulted in increased funds going directly to the suppliers of services. In El Salvador, however, autonomous community health boards created decentralized funds based on community-initiated user fees for ambulatory care (12). We are unaware of comparable instances in sub-Saharan Africa. We have found no published information on cost-sharing revenues being used for the development of human resources, including the payment of incentives to staff receiving very low salaries. Here we present the results of a community-based cost-sharing scheme that was developed and implemented by communities themselves in Uganda's Kabarole District. Our principal aims were to investigate the impact of user fees on the utilization of outpatient health services and to discover how staff perceived an incentive programme.
Kabarole District cost-sharing scheme
Kabarole District facilitated the introduction of cost sharing among government health units on the basis of the ability of communities to pay for services. The process of introducing cost sharing was supported by the locally elected representatives of the village local councils and implemented by health unit management committees. The communities were represented on these committees by several people. The relationships between the committees and the respective communities were generally good.
The cost-sharing initiative was driven by the communities. The role of the district health management team and the district administration was to inform communities about their options and to help them to begin pilot projects if they decided to initiate cost sharing. The first step was always a public information session in the catchment area of a health care facility. The members of the district health management team and representatives of the district administration discussed the options and implications of cost sharing in this forum. The political representatives at village and subcounty level were particularly involved in this process. The local councils, elected by the communities, usually had their trust. After the initial information session, several public meetings in the respective communities were held by the local councils and the chiefs, and all community members were invited to attend. …