AFFORDABILITY, COST-EFFECTIVENESS AND EFFICIENCY OF PRIMARY HEALTH-CARE - THE BAMAKO INITIATIVE EXPERIENCE IN BENIN AND GUINEA

Since 1986 two West African countries, Benin and Guinea, have been act ively reorganizing their peripheral health systems according to strate gies subsequently called the ''Bamako Initiative''. Two preceding arti cles described the strategies implemented and the increased effectiven ess of primary health care (PHC) witnessed over a period of six years. This article presents an analysis of cost and coverage data from bian nual monitoring sessions between 1988 and 1993 in approximately 200 he alth centres in Benin and 214 in Guinea. In order to assess affordabil ity, the total and per capita recurrent costs for operational health c entres are analysed and then compared. The cost analysis reveals a mea n total cost per health centre per year of slightly over US$11,000 in Benin and nearly US$9,000 in Guinea. The median cost per capita per ye ar is approximately US$1.0 in Benin and between US$0.60 and US$0.80 in Guinea. Comparisons of these costs between regions, health centres an d over time (as coverage levels evolved) show very little variation in either country. Cost-effectiveness is estimated by allocating these c osts to immunization, antenatal and curative care and comparing them t o the coverage achieved with these interventions. First, the cost-effe ctiveness of the Bamako Initiative (BI) system as a whole is analysed. The cost per fully vaccinated child is calculated at US$10.9 in Benin and USS8.8 in Guinea. The cost per woman receiving at least three ant enatal visits is US$7 in Benin and US$4.7 in Guinea. For curative care , cost per full treatment is US$1.6 in Benin and half this amount in G uinea. Cost-effectiveness is variable between regions, health centres and over time. An analysis of the characteristics of the most and leas t cost-effective centres reveals that these differences in cost-effect iveness are mainly caused by the coverage levels achieved, since total costs are relatively stable. Finally the efficiency of drug managemen t and prescriptions as well as of outreach for the expanded programme of immunizations (EPI) is estimated by relating specific drug and outr each costs to the number of beneficiaries. The average cost of drugs p er treatment is around US$0.5 in Benin and around US$0.3 in Guinea. Co st analysis of outreach activities undertaken for EPI in Guinea reveal ed a similar average cost per child completely vaccinated for health c entres with different intensities of outreach (approximately USS10) an d an additional cost per child vaccinated attributable to outreach of US$1-2. (C) 1997 by John Wiley & Sons, Ltd.