Strategies for promoting equity: experience with community financing in three African countries.

Although the need for a pro-poor health reform agenda in low and middle income countries is increasingly clear, implementing such policy change is always difficult. This paper seeks to contribute to thinking about how to take forward such an agenda by reflection on the community financing activities of the UNICEF/WHO Bamako Initiative. It presents findings from a three-country study, undertaken in Benin, Kenya and Zambia in 1994/95, which was initiated in order to better understand the nature of the equity impact of community financing activities as well as the factors underlying this impact. The sustained relative affordability gains achieved in Benin emphasise the importance of ensuring that financing change is used as a policy lever for strengthening health service management in support of quality of care improvements. All countries, however, failed in protecting the most poor from the burden of payment, benefiting this group preferentially and ensuring that their views were heard in decision-making. Tackling these problems requires, amongst other things, an appropriate balance between central and local-level decision-making as well as the creation of local decision-making structures which have representation from civil society groups that can voice the needs of the most poor. Leadership, strategy and tactics are also always important in securing any kind of equity gain-such as establishing equity goals to drive implementation. In the experiences examined, the dominance of the goal of financial sustainability contributed to their equity failures. Further research is required to understand what equity goals communities themselves would prefer to guide financing policy.

The equity impacts of community financing activities in three African countries.

Although the Bamako Initiative from its very beginning was caught up in wider debates about the potential equity impact of any form of user financing, to date there has been little empirical investigation of this impact. This three-country study, undertaken in Benin, Kenya and Zambia in 1994/95, was initiated to add to the body of relevant evidence. It sought to understand not only what had been the equity impacts of community financing activities in these countries but also how they had been brought about. As a result, it investigated equity primarily through consideration of the design of these financing activities and through the perceptions of different actors, within a limited number of purposively selected geographical areas in each country, about their strengths and weaknesses. Additional data on utilization were either collected during the course of the study (Kenya) or drawn from other available studies (Benin and Zambia). Key issues considered in the studies' assessment of equity were the extent to which both relative and absolute affordability gains were achieved, as well as as an influence over both the distributional and procedural justice of the financing activities, the pattern of decision-making. Across countries there was evidence of relative affordability gains in Benin and Kenya, but Kenyan gains were not sustained over time and no such gains were identified in Zambia. In addition, no country had given attention either to the issue of absolute affordability, through the implementation of effective exemption mechanisms to protect the poorest from the burden of payment, or to the establishment of community decision-making bodies that effectively represented the interests of all groups including the poorest. Overall, therefore, although the Benin Bamako Initiative programme might be judged as successful in terms of what appear to be its own equity objectives, the other two countries' schemes had clear equity problems even in these terms. The experience across countries also highlights the unresolved question of whether equity is concerned with the greatest good for the greatest number or with promoting the interests of the most disadvantaged.

Ageing and poverty in rural Kenya: community perception.

Poverty is widespread among rural African elderly and associated with poor health and unsatisfactory access to health care. The purpose of this study was to determine community perception of the poorest in a community in rural Kenya, more specifically to identify factors considered by community members as associated with poverty in their midst. There is need to protect the aged members of the society from payment for health care and to include them in decision-making process. This study was undertaken in seven sites in Kisumu and Homa Bay districts in western Kenya where the Bamako Initiative was first launched, in 1987, calling on UNICEF and WHO to help accelerate the implementation of primary health care at district level, giving priority to women and children. Two household interview baseline surveys comprising 210 and 87 households, respectively, corroborated by the more qualitative approaches of participatory rural appraisal (PRA) and focus group discussions were conducted. This article analyses the importance of ageing as perceived by the communities as a factor associated with poverty.

Health information for district level planning: a cross-sectional household survey in rural Kenya.

Health care planning and management in sub-Saharan Africa is being decentralised, and health information systems need to meet new needs. This study in rural Kenya explored the feasibility of a cross-sectional household health interview survey to help district-level health planning. Heads of 390 households were interviewed about health-related factors like housing standard, water supply, sanitation, recent illness, and health care use. Half of all households lived on farming. Access to water sources was poor, but latrine coverage was high. Of all disease episodes 26% were respiratory, 18% gastrointestinal and 10.5% malaria. Rates of illness episodes were low (1.0 day of illness/person/30 days), and 40% of episodes were taken to a modern service provider like a dispensary, health centre or hospital. The survey generated much information on household characteristics, illness episodes and action taken, data that was not available through the routine health information system. Survey costs were estimated at 15 US cents per resident in the project area, a large proportion of which was absorbed by computerized data processing, but may be reduced to about half. If conducted once every three or four years, a survey of this kind would be affordable within the ordinary recurrent district health budget and would provide useful planning and management information.

A longitudinal health interview survey in rural Kenya: potentials and limitations for local planning.

A twelve-month longitudinal household health interview survey in Machakos District (now Makueni District), Kenya, during 1991 covered 390 households randomly selected from 12 village clusters. The survey focused on recent disease symptoms and signs, illness severity, temporary disability and care-seeking behaviour. The total number of reported disease episodes was 9,393, (4.4 per person) with more episodes reported by adult females than by adult males. The disease pattern was dominated by malaria (39.6% of all reported episodes) and respiratory tract diseases (23.1%), followed by gastrointestinal illness (10.7%), joint/muscle disorders (6.4%), injuries (5.4%) and skin conditions (4.8%). Self-medication took place in 39.9% of episodes, while care was sought at hospitals or clinics in 32.1%. This survey generated information useful for local health care planning and management, especially regarding local perception of illness episodes and health care utilization. Respondents developed signs of interview fatigue, however, and the completeness and accuracy of symptom descriptions by the lay interviewers are uncertain. Survey costs were about USD 24,700, one third of which was spent on field work, another third on computerized data processing. Utility in relation to costs is likely to be modest. Improvement of the health information system for local planning and management may be equally or better served by selective improvement of the existing routine reporting system combined with occasional cross-sectional household surveys.