LOCAL COST-SHARING IN BAMAKO INITIATIVE SYSTEMS IN BENIN AND GUINEA -ASSURING THE FINANCIAL VIABILITY OF PRIMARY HEALTH-CARE

The fourth in a series of five, this article presents and analyses dat a on cost recovery and community cost-sharing, two key aspects of the Bamako Initiative which have been implemented in Benin and Guinea sinc e 1986. The data come from approximately 400 health centres and result from the six-monthly monitoring sessions conducted from 1989 to 1993. Community involvement in the financing of local operating costs in th e two national scale programmes is also described. In Benin and Guinea , a user fee system generates the community financed revenue with the aim of covering local operating costs including drugs. Health worker s alaries remain the responsibility of the government and donor funding covers vaccine and investment costs. Village health committees manage and control resources and revenue. The community is also involved in d ecision making, strategy definition and quality control. In Benin in 1 993, community financing revenue amounted to about USS0.6 per capita p er year and generally covered all local recurrent non salary costs exc ept vaccines and left a surplus. Although total costs and revenues wer e slightly lower in Guinea for the same period, over-all, user fee rev enue (around US$0.3 per capita per year) covered local recurrent costs (not including salaries or vaccines). A comparison of costs and reven ue between regions and individual health centres revealed important di fferences in cost recovery ratios. In Benin, some centres recovered mo re than twice the local costs targeted for community financing. Twenty -five per cent of centres in Guinea did not manage to cover their desi gnated local recurrent costs. The longitudinal analysis showed that th e level of cost recovery remained stable over time even as preventive care (and especially EPI) coverage rose significantly. To better under stand the most important characteristics affecting cost recovery level s, best performing health centres in terms of cost-recovery levels in 1993 were compared to worst performing centres. This analysis showed t hat the size of the target population of the health centre is a key de terminant of cost-recovery in both countries. In addition, in Guinea t he utilization of curative care linked to geographical access and in B enin the average revenue per case linked to the number of deliveries p roved to be additional factors of importance. In best performing centr es, financial viability improved over time in both countries between 1 990 and 1993. Finally, the implications of these conclusions for the p lanning of health centre revitalization in West Africa are discussed. (C) 1997 by John Wiley & Sons, Ltd.