By Brian Nolan
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Extra resources for Cost recovery in public health services in Sub-Saharan Africa
See, for example, World Bank (1987), pp. 2, p. 66; and World Bank (1993a), 107. Some countries have succeeded in reducing the share of expenditure going to tertiary care, however. Zimbabwe, for example, did so during the 1980s. 4. Thomas, Lavy, and Strauss (1992) and Lavy and others (1992) have made interesting attempts to relate measures of the availability and quality of health care to health status in Côte d'Ivoire and Ghana, respectively. 5. De Ferranti (1985) argues on this basis that in some instances fees may be appropriate, even if the cost of collecting them exceeds the revenue raised.
As noted above, these differences are a reflection of the differences in "models": the general assumption under the Bamako Initiative is that most people will be able to pay something for basic care at the community level, whereas the "standard model" generally assumes that the poor will be protected from charges. ''Poor" and even "indigent" are relative terms whose meanings change from one country to another, but within a particular country the concepts are usually clearly distinguished. The methods used to implement exemptions also vary widely, and this may be an area in which countries will be particularly anxious to learn from one another.
Is there any evidence on the impact of implementing/increasing fees on the utilization of different types of health services (health clinics versus hospital outpatient versus hospital inpatient)? What about utilization by higher versus lower income groups (or proxies such as urban/rural)? Does health insurance play a role? Page 17 Table 3-2. )Charges in some projects in addition to national systemNo national charges but in some projectsAngolaNo, but to be introducedNoNoBotswanaNo (except 1 minor fee)NoNoEquatorial GuineaYes but minimalEthiopiaYes (1951), but to be reinforcedYes, some facilities raising "extra" revenue, ad hocNoThe GambiaYes (1988)YesNoGhanaYes (1970s)Yes, since late 1980s in some projectsNoGuinea-BissauYes but minimal (1976)Yes, since 1990 in some projects in 1 out of 9 regionsNoKenyaYes (extended 1989/1992/3)Some projects predate national feesNoLesothoYes (1980, raised in 1988)Yes, in projects in 5 out of 18 districtsNoMozambiqueYes (198587) but only operating in some areasNoNamibiaYesNoNoNigeriaNational fees policy, but great variation across districts and states in districts and states in practiceSao TomeNo, to be introducedNoNoSierra LeoneYesYes, in 7 out of 13 districtsNoSudanYes, for hospitals (1982)Yes, many hospitals/centers have other chargesSwazilandYes (increased 1984)Yes, some community financing projectsNoTanzaniaNo, being consideredNoNoUgandaNo, to be introducedNoYes, widespreadZambiaYes but minimal (1989)Yes, additional fees in some projects since late 1980sNoZimbabweYes (enforced 1992)NoNo presented country by country in annex B.