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Objectives: To compare the level of availability and rational use of drugs in primary health care (PHC) facilities where the Bamako Initiative (BI) drug revolving fund programme has been operational, with PHC centres where the BI-type of drug revolving fund programme is not yet operational., Methods: The study was undertaken in 21 PHC centres with BI drug revolving funds and 12 PHC centres without BI drug revolving funds, all in Enugu State of Nigeria. Data were collected on the essential and non-essential drugs stocked by the facilities. Drug use was determined through analyses of prescriptions in each health centre. Finally, the proportion of consumers that were able to remember their dosing schedules was determined., Findings: An average of 35.4 essential drugs was available in the BI health centres compared with 15.3 in the non-BI health centres (p < 0.05). The average drug-stock was adequate for 6.3 weeks in the BI health centres, but for 1.1 weeks in non-BI health centres (p < 0.05). More injections (64.7 vs. 25.6%) and more antibiotics (72.8 vs. 38%) were prescribed in BI health centres than in the non-BI health centres (p < 0.05). The BI health centres had an average of 5.3 drugs per prescription against 2.1 in the non-BI health centres. However, the drugs prescribed by generic name and from the essential drug list were higher in the BI health centres (80 and 93%) than the non-BI health centres (15.5 and 21%, respectively) (p < 0.05)., Conclusion: It was observed that the BI facilities had a better availability of essential drugs both in number and in average stock. However, the BI has given rise to more drug prescribing, which could be irrational. The findings call for strategies to ensure more availability of essential drugs especially in the non-BI PHC centres as a strategy to decrease medical costs and improve the quality of PHC services, while promoting rational drug use in all PHC centres. More detailed studies (for example, by focus group discussion or structured interviews) should be undertaken to find out reasons for the over-prescription and to develop future interventions to correct this.

Decentralization is commonly championed as a means for achieving equity. To date, however, there has been little discussion of the mechanisms underlying this relationship, and several of the few empirical investigations that have addressed the topic have found the converse; that decentralization has exacerbated inequalities. This article examines the performance and equity in financing of the Honduras Ministry of Health's (MOH) decentralized user fee system. The MOH of Honduras established a national user fee policy in 1989. It provided a framework of rules and regulations and decentralized administration of the system to the regional offices. A survey conducted under the auspices of this study provided detailed information about the structures and operations of MOH user fee systems. The survey revealed that the systems vary markedly by region, creating horizontal inequities, and that they have numerous other shortcomings. The average price of a consultation is low, US dollars 0.16, and revenues have consistently equalled just 2% of MOH expenditures. The systems' administrative costs are equal to 67% of their revenues. Eliminating the user fee systems in all but the national and regional hospitals would actually save money and/or enable the MOH to provide more care. Average consultation prices are highest in health posts, intermediate in centres and lowest in the national hospitals, thereby encouraging the inappropriate use of the MOH's pyramidal referral system and fostering MOH inefficiency. Fee levels and exemption practices are horizontally and vertically inequitable. The likelihood of paying for an ambulatory visit is highest at a health post, 89%, and lowest at a hospital, 49%. Individuals from the poorest one-fifth of households are the most likely to have to pay for care. Honduras' experience demonstrates that a decentralized user fee system is not necessarily equitable, and that, more generally, the gains that can be realized from decentralizing user fee systems are not automatic. They must be anticipated, planned for and cultivated by a well-designed and well-implemented initiative that is not a single, one-time event, but rather a dynamic, on-going enterprise.

Developments in health are easily among the best known human development indicators. Comparisons of life expectancy, infant mortality, access to safe water and similar data indicate the positions of individual countries. The political and economic processes which these indices reflect, or which inform the nature of health policy, are often not as clear or visible. These structural factors are either frequently ignored or mentioned only in passing, as illustrated in a recent paper published in this journal on the private medical enterprise in Nigeria (Ogunbekun et al. 1999). According to the authors, the generally low quality of public health services and high user fees have combined to make private medicine the 'unavoidable choice' of Nigerians. They identify benefits of private medicine as higher technical efficiency and contributing to fill the gap created by inadequate public sector services and to medical training. This paper argues that these claims are exaggerated, and that the authors seem to ignore Nigeria's political and economic processes, the health seeking behaviour of Nigerians, as well as the prevailing causes of morbidity and mortality. It is suggested that whereas the contributions of private medicine are significant, there are also several limitations, some of which originate from its for-profit raison d'être. The ultimate aim of health development must include improved access to services and better health status for the majority of the people. Without any form of public supported programme of payments in Nigeria, these objectives are circumscribed, especially with high fees in the private system. It is concluded that while private medicine will continue to be available for those who can afford it, it is unlikely to provide solutions to Nigeria's morbidity and mortality problems, particularly in relation to epidemics such as the growing burden of HIV/AIDS.

The private health sector has been growing rapidly in many low and middle income countries, yet not enough is known about its sources of finance or characteristics of its users. Moreover, health care reform measures are leading to alterations in the mix of public and private finance and provision, increasing further the need for information. This paper presents and evaluates some research methods which can be used to collect information relevant to considering policies on the public/private mix. They comprise a household survey, a health diary and interview survey, a bed census, and a health resource survey. Each method is described as it was used in a study in a large urban setting in Thailand, and strengths and weaknesses of the methods are identified. The use of data to estimate the shares of public and private finance and provision, and particularly private sources of finance of public hospitals and public sources of finance for private hospitals, is demonstrated. Policy issues highlighted by the data are identified.

Ivermectin mass distribution for the control of onchocerciasis in Uganda began in 1991. This report describes a community based ivermectin distribution programme covering two foci in the Kabarole district which have an estimated 32,000 persons infected and another 110,000 at risk. Through nodule palpation in adult males, 143 villages were identified where nodule prevalence exceeded 20%. Skin snips were also taken from a sample of the population to measure changes in community microfilarial load (CMFL) with treatment. The delivery programme was integrated into the district health management structure, and used community volunteers supervised by medical assistants from adjacent health facilities for annual ivermectin distribution campaigns. After initial efforts by the community to support distributors in-kind proved inadequate, ivermectin distributors earned money retailing condoms as part of the social marketing component of district STD/AIDS programme. Reduction in the CMFL ranged from 40-62% twelve months after the second ivermectin treatment in three villages, and from 69-84% six months after the fourth round of treatment in two villages. After four years of treatment, 85% of eligible persons were receiving ivermectin from community volunteers in each treatment cycle. Drop out rates among volunteers did not exceed 20% over the four years reported here. The direct cost of treatment was US $0.29 per person. Among the reasons for low per-person treatment costs were the strong supervisory structure, the presence of health centres in the foci and a well developed and capable district Primary Health Care management team.

The widespread uncontrolled introduction of user fees in any developing country is likely to have a disastrous impact on poorer patients. Furthermore, traditional targeting schemes aimed at their exemption are often expensive, difficult to administer and ineffective at reaching those in greatest need. This research study examines how user fees can raise revenue and target poorer patients, under the right market conditions, without resorting to costly targeting schemes. The authors draw their findings from case studies of cost recovery in the health and population sectors in Bangladesh. The mechanism suggested in the paper is to use self-selection. It is argued that under certain market conditions poorer patients will choose the health-care option that is appropriate to their means. They will thus identify themselves as poor without having to be selected or tested by an independent authority. This self-selection allows the relevant authorities to cross-subsidize their market choice by over-charging the non-poor in other segments of the market.

Many low and middle income countries have inherited publicly funded and provided health services, often operating at relatively low levels of technical efficiency. Changing ideas about the management of the public sector, in particular stemming from new public management theory, are spreading to these countries, whether directly or via the recommendations of multilateral and bilateral aid agencies. Pronouncements of agencies such as the World Bank imply that competitive contracting with the private sector is likely to improve the efficiency of services provision. However, very little evidence is available on whether this is likely to be the case, and in what circumstances delivery of services through contracts with the private sector is likely to be preferable to direct provision by the public sector. This paper draws on evidence from five country case-studies of contractual arrangements, in Bombay, Papua New Guinea, South Africa, Thailand and Zimbabwe, done through collaborative research between the LSHTM Health Economics and Financing Programme and local researchers in each country. A common evaluative framework was applied in each country to selected, existing contractual arrangements. Services provided under contract and evaluated included catering, cleaning, security, diagnostic services and whole hospitals. Information is presented on the design of contracts, the process of agreeing contracts including the extent of competition, and the monitoring of contract performance. A variety of evidence, including information on the relative cost and quality of contracted out versus directly provided services in the case of South Africa, Thailand, and Bombay, is used to explore whether or not contracting out to the private sector represented a preferable means of service provision. This analysis, together with information on the capacity of the agency letting the contract, and on the wider environment including the level of development of the private sector, is used to identify which aspects of the contracting process and the context in which it takes place are important in influencing whether or not contracting with the private sector is a desirable means of service provision.

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 combined effects of increasing demand for health services and declining real public resources have recently led many governments in the developing world to explore various health financing alternatives. Faced with a significant decline during the 1980s in its real per capita expenditures, the Kenya Ministry of Health (MOH) introduced a new cost sharing programme in December 1989. The programme was part of a comprehensive health financing strategy which also included social insurance, efficiency measures, and private sector development. Early implementation problems led to the suspension in September 1990 of the outpatient registration fee, the major revenue source at the time. In 1991, the Ministry initiated a programme of management improvement and gradual re-introduction of an outpatient fee, but this time as a treatment fee. The new programme was carried out in phases, beginning at the national and provincial levels and proceeding to the local level. The impact of these changes was assessed with national revenue collection reports, quality of care surveys in 6 purposively selected indicator districts, and time series analysis of monthly utilization in these same districts. In contrast to the significant fall in revenue experienced over the period of the initial programme, the later management improvements and fee adjustments resulted in steady increases in revenue. As a percentage of total non-staff expenditures, fiscal year 1993-1994 revenue is estimated to have been 37% at provincial general hospitals, 20% at smaller hospitals, and 21% at health centres. Roughly one third of total revenue is derived from national insurance claims. Quality of care measures, though in some respects improved with cost sharing, were in general somewhat mixed and inconsistent. The 1989 outpatient registration fee led to an average reduction in utilization of 27% at provincial hospitals, 45% at district hospitals, and 33% at health centres. In contrast, phased introduction of the outpatient treatment fee beginning in 1992, combined with somewhat broader exemptions, was associated with much smaller decreases in outpatient utilization. It is suggested that implementing user fees in phases by level of health facility is important to gain patient acceptance, to develop the requisite management systems, and to orient ministry staff to the new systems.

New evidence on the quality of health care from public services in Niger is discussed in terms of the relationships between quality, costs, cost-effectiveness and financing. Although structural attributes of quality appeared to improve with the pilot project in Niger, significant gaps in the implementation of diagnostic and treatment protocols were observed, particularly in monitoring vital signs, diagnostic examination and provider-patient communications. Quality improvements required significant investments in both fixed and variable costs; however, many of these costs were basic input requirements for operation. It is likely that optimal cost-effectiveness of services was not achieved because of the noted deficiencies in quality. In the test district of Boboye, the revenues from the copayments alone covered about 34% of the costs of medicines or about 20% of costs of drugs and administration. In Say, user fees covered about 50-55% of the costs of medicines or 35-40% of the amount spent on medicines and cost-recovery administration. In Boboye, taxes plus the additional copayments covered 120-180% of the cost of medicines, or 75-105% of the cost of medicines plus administration of cost recovery. Decentralized management and legal conditions in the pilot districts appeared to provide the necessary structure to ensure that the revenues and taxes collected would be channelled to pay for quality improvements.

In African health sectors, the importance of protecting the very poor has been underscored by increased reliance on user fees to help finance services. This paper presents a conceptual framework for understanding the role means testing can play in promoting equity under health care cost recovery. Means testing is placed in the broader context of targeting and contrasted with other mechanisms. Criteria for evaluating outcomes are established and used to analyze previous means testing experience in Africa. A survey of experience finds a general pattern of informal, low-accuracy, low-cost means testing in Africa. Detailed household data from a recent cost recovery experiment in Niger, West Africa, provides an unusual opportunity to observe outcomes of a characteristically informal means testing system. Findings from Niger suggest that achieving both the revenue raising and equity potential of cost recovery in sub-Saharan Africa will require finding ways to improve informal means testing processes.

Attaining efficiency in a health care system with a budget constraint involves increasing the utilization of the most cost-effective services. This can be achieved by adjustments to prices, cost curves, or demand curves. In this paper, the potential for demand curve adjustments is examined by selecting two apparently cost-effective services (prenatal care and childhood immunization against tuberculosis), and analyzing the factors explaining their utilization. Data from recent household surveys in Burkina Faso and Niger are used. A multivariate analysis of utilization employs income, price, and taste variables. Utilization is highly sensitive to the distance which must be travelled to the health facility, a price, and taste variables. Utilization is highly sensitive to the distance which must be travelled to the health facility, a price variable. Members of certain ethnic groups tend to use the services less, other things being equal. The importance of demand-side factors like ethnicity points to certain kinds of policy interventions like information, education and communication activities which could increase the utilization of cost-effective services.

This study aimed to test whether voluntary agencies provide care of better quality than that provided by government with respect to primary curative outpatient services in Dar-es-Salaam. All non-government primary services were included, and government primary facilities were randomly sampled within the three districts of the city. Details of consultations were recorded and assessed by a panel who classed consultations as adequate, inadequate but serious consequences unlikely, and consultations where deficiencies in the care could have serious consequences. Interpersonal conduct was assessed and exit interviews were conducted. The study found that government registers of non-government 'voluntary' providers actually contained a high proportion of for-profit private providers. Comparisons between facilities showed that care was better overall at voluntary providers, but that there was a high level of inadequate care at both government and non-government providers.