Bamako Initiative Research Articles

Power Resources in Health District Governance in Burkina Faso

Introduction; The pluralistic nature of the governance of the health system with the multiplicity of actors disrupts power relations. Since the adoption of the Bamako Initiative in 1987 in Burkina Faso, we have noted the presence of community representatives in the decision-making space of health districts. They participate alongside government representatives in the decision-making process. This article aims to analyze the influence of the different actors involved in the governance of a health district in Burkina Faso. A total of 32 people were included in the study. These people were divided into three main groups: members of the district team (n=9), managers of the government's decentralized technical services (n=8) and community representatives (n=15). The data were collected through individual interviews. The content analysis method was used. NVIVO software was used for data processing. The results indicate that community representatives have little influence in the decision-making process at the health district level. Indeed, all the resources that allow actors to influence exchanges are beyond their reach. Language skills, expertise, and economic capital are the main resources that are mobilized in this space. They are easily mobilized in interactions by both health district officials and community representatives. As a result, the views of the communities are poorly taken into account in the governance of health districts in Burkina Faso. The article notes that mastery of the language of communication, economic situation, and expertise on health issues give more scope for action to health district officials than to communities.

Does abolishing user fees for family planning increase contraception use? An impact evaluation of the national policy in Burkina Faso.

BackgroundUnmet needs for contraception constitute a major public health problem in sub-Saharan Africa. Several mechanisms have been tested to reduce the financial barrier and facilitate access to family planning services, with inconclusive results. Based on the positive impacts following the introduction of free health care for pregnant women, Burkina Faso decided to extend its national policy and abolished direct payment for family planning services. This study aims to evaluate the impact of this policy on contraceptive use and unmet needs for contraception among women of reproductive age (WRA) in Burkina Faso.MethodsThis study uses two different study designs to examine the impact of a user fee removal policy on contraceptive use across a panel of 1400 households randomly selected across eight health districts. Data were collected using a standardized socio-demographic questionnaire at three different time points during the pilot and scale-up phases of the fee abolition program. The questionnaire was administered six months after the launch of the pilot fee abolition program in four health districts. For the remaining four health districts, the survey was conducted one year prior to and six months after the implementation of the program in those areas. All WRA in the households were eligible to participate. A cross-sectional study design was used to determine the association between knowledge of the fee abolition policy among WRA and actual use of contraceptives by WRA six months after the policy’s implementation and across all eight districts. Additionally, a pre-post study with a non-randomized, reflexive control group was designed using repeated surveys in four health districts. Hierarchical logistic mixed effects models were adjusted for a set of time-variant individual variables; the impact was assessed by a difference-in-differences approach that compared pre-post changes in contraception use in women who knew about the new policy and those who did not.ResultsOf the 1471 WRA surveyed six months after the removal of user fees for family planning services, 56% were aware of the policy’s existence. Knowledge of the fee abolition policy was associated with a 46% increase probability of contraceptive use among WRA six months after the policy’s implementation. Among the subset of the participants who were surveyed twice (n = 507), 65% knew about the fee removal policy six months after its introduction and constitute the intervention group. Pre-post changes in contraceptive use differed significantly between the intervention (n = 327) and control groups (n = 180). Removing user fees for family planning led to an 86% (95% confidence interval (CI) = 0.49, 1.31) increase in the likelihood of using contraception. In the study area, the policy reduced the prevalence of unmet needs for contraception by 13 percentage points.ConclusionsRemoving user fees for family planning services is a promising strategy to increase access to, and reduce unmet needs for, contraception. A broader dissemination of the policy’s existence will likely increase its impact on the overall population.

Community-based mutual aid for improving financial access tos healthcare: case study of 150 community-based organizations in Cameroon

Background: Financial access to health care has been sharply reduced in Africa following the introduction of cost recovery recommended by the Bamako initiative of 1987. Like in many countries in the world, in Cameroon, community-based organizations (CBO) which assist their members in the event of a financial crisis, death, funeral, birth, marriage, etc. added financial assistance in case of illness to alleviate this situation. This study aimed to determine models of financial assistance practiced by these organizations to rescue their members in event of illness.Method: Study was based on a sample of 150 CBO selected for convenience in 3 zones, including 50 in urban areas, 50 in semi-urban areas, and 50 in rural areas. Previously trained interviewers organized group discussions to collect data from these organizations using structured interview guide. The analysis of data collected was done manually.Results: The results show that 82.66% of organizations practice the "rescue quest model", 10.67% the "lump sum health assistance model", 2.67% "health tontine model", 2% "sickness deposit model", and 2% "subcontracting model" with an insurance company. The analysis shows that the "health tontine" and "sickness deposit" models are more forward-looking because they can make money available in time, before seeking care/before disease worsens.Conclusions: The systematization of these models could make it possible to mobilize funds on a community basis to extend the coverage of the financial risk linked to the disease to the populations of the informal and rural sector.

Health district governance and power relations in Burkina Faso

Introduction: The pluralistic nature of the governance of the health system with the multiplicity of actors disrupts power relations. Since the adoption of the Bamako Initiative in 1987 in Burkina Faso, we have noted the presence of community representatives in the decision-making space of health districts. They participate alongside government representatives in the decision-making process. This article aims to analyze the influence of the different actors involved in the governance of a health district in Burkina Faso. Methodology: A total of 32 people were included in the study. These people were divided into three main groups: members of the district team (n=9), managers of the government's deconcentrated technical services (n=8) and community representatives (n=15). The data was collected through individual interviews. The content analysis method was used. NVIVO software was used for data processing. Results: The results indicate that community representatives have little influence in the decision-making process at the health district level. Indeed, all the resources that allow actors to influence exchanges are beyond their reach. Language skills, expertise, and economic capital are the main resources that are mobilized in this space. They are easily mobilized in interactions by both health district officials and community representatives. As a result, the views of the communities are poorly taken into account in the governance of health districts in Burkina Faso. Conclusion: The article notes that mastery of the language of communication, economic situation, and expertise on health issues give more scope for action to health district officials than to communities.

Mutual insurances in Africa: Issues and perspectives

RésuméDès la fin des années 1970, la promotion de la communauté et de la participation des populations au système de santé renforcent l’idée que les mutuelles de santé sont des acteurs potentiellement majeurs de l’extension de la couverture contre les risques de santé. Mais l’histoire de la mutualité en Afrique a été rapidement parsemée d’embûches. Les plans d’ajustement structurel, l’augmentation de la contribution financière des usagers sous l’impulsion de l’initiative de Bamako, ont marqué un coup d’arrêt à l’esprit des mutuelles communautaires. Aujourd’hui les mutuelles sont de nouveau au cœur des initiatives internationales et nationales avec la promotion de la CSU (couverture sanitaire universelle). Mais elles doivent dépasser leurs carences historiques par la professionnalisation et l’obligation d’adhésion. Ce mouvement semble engagé tout en étant confronté au défi de préserver la place des communautés dans les systèmes de santé, principe fondateur du mouvement mutualiste.

Failure of User Fees

The end of health care user fees is within sight for an increasing number of African countries whom this policy was imposed upon in the late 1980 and early 1990s. User fees were part of structural adjustment programs (SAPs) dictated to developing countries by the World Bank, influenced by the Bamako Initiative. The West African country of Mali is presently working towards eliminating user fees and implementing Universal Health Care (UHC). This paper investigates health indicators of pregnant women in Mali during user fee implementation to show the negative impact of the policy, and extrapolates to future outcomes when UHC is available. For example, when user fees were removed in pilot projects, Caesarean costs decreased from 95-136 $USD to 0.80-10 $USD, and Caesarean rates increased by a factor of 2.5. As well, with user fees, Malian citizens had to pay an average of 2 months of salary per health care visit, severely limiting those who could access services. These numbers show that vulnerable individuals in Mali, such as expecting mothers, likely experience unmet need for healthcare services in Mali, and the current user fees system is insufficient and inequitable.

Informal economy as a “good” “bad practice”? Informal sale of medicines in Lomé

PurposeThe purpose of this paper is to expound on the idea that informal economy is a “conforming” situation, based on the informal sale of medicines in Lomé.Design/methodology/approachThe paper takes the form of a case study based on interviews.FindingsThe case makes it possible to understand that the quality‐price ratio mainly explains the existing practices, inducing an immediate satisfaction of the purchasers. Indeed, the average income in developing countries is very low and consumers are inclined to buy these products because of their low prices (i.e. “Bottom of the Pyramid” issues – BOP).Research limitations/implicationsTo say that the informal economy “conforms to the rules” is to assert its institutional dimension and suggest it should be considered within the categories of institutionalization. It is also a scathing criticism of the logic of international organizations and CSR, one that is unlikely to crop up in the so‐called audited reports.Practical implicationsInformal economy gives rise to innovations and the development of a kind of entrepreneurship dissimilar to that of business schools and the very honorable “social entrepreneurs”. Concepts such as leadership, motivation, negotiation power, organizational learning, strategy, competitive advantage, diversity and the like have coherent materializations, albeit structurally different in origin from the received wisdom about them.Social implicationsThe argument of this research is based on the observation that informal economy is a situation just as “conforming” as the formal economy. It should be mentioned that in economics, grassroots collective and non‐institutionalized action is referred to as “informal economy”. It is regarded as inseparable from the formal economy – as evidenced in the case of Togo's reform of public health policy following the Bamako Initiative and its consequences as studied in this paper – but receives less attention despite numerous studies.Originality/valueThis paper presents a real field study. The interviews were carried out near all the categories of actors implied in the drugs sales: wholesalers and retailers and customers (primary wholesalers, local dealers, retailers, patients).

Funding of a free healthcare campaign in a rural district of Cameroon: Optimizing the role of civil society in sub-Saharan Africa

Financial barriers represent a major obstacle to access to health care in sub-Saharan Africa and thus to the implementation of the Bamako Initiative. We describe an experience in which a civil society organization financed a free healthcare campaign in a rural health district in Cameroon. In all, 2,073 patients received free consultations, laboratory tests, and drugs. Adults older than 40 years accounted for 55.7% of all patients. The most frequent diseases were: osteoarticular conditions (24.1%), malaria (20.8%), and intestinal parasitosis (12.5%). In health systems financed mainly by cost recovery, some population needs remain uncovered by health services. There is a need to involve and reinforce the role of civil society in health system financing. It can help to pool more funds and improve the management of health resources to increase financial access to health care for poor people.

Remind me again: why are we here?

On pondering the challenges of communi-ty-based health insurance, we are reminded of a scene in a movie. The leader of a war, after losing many battles and wasting the lives of thousands of men, asks his lieuten -ant: “Remind me again: why are we here?” In the midst of all the battles, war itself had become the goal and the ultimate goal of reaching stability and peace had been forgotten. In other words, the means had become the end.Similarly, in many community-based health insurance schemes, the multitude of logistical demands of initiating, managing and maintaining the schemes seem to over -shadow their original purpose – the health and well-being of a specific community and its members. In addition, the implementa -tion of community-based health insurance in low-income countries, especially in sub-Saharan Africa, is too rigid: the designs are often standardized and lack the necessary flexibility to adapt to the local context.The story of community-based health insurance dates back to the Alma-Ata Conference in 1978, when health ministers made a commitment to reform health sys-tems and extend universal primary health care to poor people. They failed to achieve this due to insufficient resources and lack of political will. Subsequently, the Bamako Initiative of 1987 promoted the introduc-tion of user fees and community involve-ment (and management) of primary care in Africa to achieve universal coverage.

Leadership and vision in the improvement of universal health care coverage in low-income countries

In Burkina Faso, as in most developing countries, the operational level of the health system is made up of Health Districts (HDs), the activities of which are typically coordinated by the District Team (DT). Assessing the the core functions of DTs, as described by WHO, shows two important weaknesses. Firstly, instructions from "above" are often implemented rather passively: DTs tend not to display much leadership. Secondly, the current organisation, based on input financing and centralised planning, does not sufficiently promote either the vision or research functions of DTs. In this article, we report our experience in the Orodora HD in Burkina Faso, where the DT's leadership and vision proved to be essential ingredients for effective health action in the district. Our description of six interventions implemented between 2004 and 2008 shows how DT leadership and vision have improved outputs at the HD level. Until 2004, the district applied static health planning. The health system was insufficiently financed and performed poorly. Faced with this situation, the DT decided to set up several priority interventions based on health care access criteria and patient concerns, while respecting and contextualizing national norms and objectives. Six interventions were then implemented. The first was ensure that quality blood (meeting transfusion security norms) was available at the District Hospital (DH), by picking blood up from the regional blood transfusion center weekly. This speeded up care at the DH, reduced the number of cases referred to the regional hospital for transfusion, and reduced neonatal and maternal mortality. The second intervention sought to improve the skills of health workers in managing emergency cases and to improve relationships with the referral hospital through the reintroduction of counter-referral procedures. This led to a decrease in unnecessary referrals and also reduced the mortality rates of serious cases. The third intervention, by implementing a decentralized approach to tuberculosis detection, succeeded in improving access to care and enabled us to quantify the rate of tuberculosis-HIV co-infection in the HD. The fourth intervention improved financial access to emergency obstetric care by providing essential drugs and consumables for emergency obstetric surgery free of charge. The fifth intervention boosted the motivation of health workers by an annual 'competition of excellence', organised for workers and teams in the HD. Finally, our sixth intervention was the introduction of a "culture" of evaluation and transparency, by means of a local health journal, used to interact with stakeholders both at the local level and in the health sector more broadly. We also present our experiences regularly during national health science symposia. Although the DT operates with limited resources, it has over time managed to improve care and services in the HD, through its dynamic management and strategic planning. It has reduced inpatient mortality and improved access to care, particularly for vulnerable groups, in line with the Primary Health Care and Bamako Initiative principles. This case study would have benefited from a stronger methodology. However, it shows that in a context of limited resources it is still possible to strengthen the local health system by improving management practices. To progress towards universal health coverage, all core functions of a DT are worth implementing, including leadership and vision. National and international health strategies should thus include a plan to provide for and train local health system managers who can provide both leadership and strategic vision.

PRM5 A REVIEW AND CLASSIFICATION OF CONTINGENT VALUATION METHOD STUDIES IN SUB-SAHARA AFRICA

The primary objective is a review, classification and critical appraisal of contingent valuation method (CVM) healthcare studies conducted in Sub-Sahara Africa based on criteria by O'Brien and Gafni (1996). The secondary objective is to determine the impact of the Bamako Initiative adopted in the early 1990s on CVM studies in the same setting. CVM African healthcare studies (willingness to pay (WTP) and willingness to accept (WTA)), were identified using a comprehensive literature search in EconoLit, Google Scholar, Medline, PubMed and Web of Science between 1981 to 2010. CVM studies evaluated included WTP and WTA studies reporting primary data were included for evaluation. Primary assessment of the studies was based on the conceptual framework for evaluation of contingent valuation of healthcare programs (5 Items)(O'Brien and Gafni 1996). Secondary assessment was based on the time horizon of publication: pre-, during- (1990s), or post- BI, and area of intervention. Twenty-four CVM studies were evaluated: all used WTP and compensating variation. Elicitation techniques were dominated by bidding game (42%), followed by dichotomous choice (33%), and then payment card and the open ended formats (12.5%). Majority of studies (83%) were published after 2000, the remainder were published in the 1990s. Interventions included insurance (25%), medication (38%), and health services (38%). Healthcare CVM studies in Sub-Sahara Africa are limited despite the introduction of Bamako Initiative. The predominance of the bidding game elicitation technique in evaluated studies may be a reflection of the actual African market conditions. There is continuing debate as to which is the most appropriate CVM for healthcare studies conducted in Africa This debate will continue until these methods are compared to actual markets. CVM studies may start to engage the political market as Africa moves towards universal health coverage.

Is the Bamako Initiative Still Relevant for West African Health Systems?

Faced with the difficulty of implementing primary health care services as proposed at Alma-Ata, UNICEF and the World Health Organization launched a new public health policy in 1987, the Bamako Initiative, to improve access to health care by revitalizing primary health care. The key principle was to decentralize retention of user fees to the local level in health centers managed by a committee of community representatives. Initially, measures were envisioned to exempt the worst-off who were unable to pay; however, these measures were never applied. Today, with most funding agencies in favor of abolishing user fees and some African countries already starting to do so, the relevance of this public policy is being reconsidered for West African countries.

Cost of stroke in Lomé (Togo).

The financial crisis that affected the healthcare systems of most developing countries in the 1980s, the ensuing need to control hospital costs, the partial disengagement of States, and the resort to policies based on cost recovery -- all these led to the restructuring of hospital systems in Africa, in accordance with the Bamako initiative, adopted by the WHO regional committee in September 1987. This restructuring required populations to pay much of the cost of their health care. In practice, however, the major obstacle to this policy of cost recovery remains poverty. Twenty years after the adoption of this initiative, we sought to evaluate the cost of hospitalisation for cerebral stroke in Togo, where there is no national health insurance programme, and to propose strategies to improve its management. This prospective study was conducted in the neurology department of the University Hospital of Lomé over a period of 12 months, from 1 January to 31 December 2005 and included 412 consecutive patients with a confirmed diagnosis according to WHO criteria and cerebral computed tomography (CT) results. This department has 30 beds in rooms categorized according to their cost to the patients: EUR 27.30 for a superior single room, EUR 18.20 for the first category standard room, EUR 13.7 euros for the second, and EUR 8.20 for the third. Patients or their family could choose their room category. Of the 412 patients included in our study, 248 (60.2%) had an ischaemic stroke (IS) and 164 (39.8%) a haemorrhagic stroke (HS). The average length of stay was 17.4 +/- 10.4 days (range: 3 to 41 days), 10.17 days (range: 3 to 24) for IS and 26.7 (range: 13 to 41) for HS. In all, 124 (30%) patients produced insurance certificates, and 288 (70%) paid directly; among the latter 152 (36.9%) patients paid their own expenses, while relatives paid for 65 (63.10%). Housewives accounted for 136 (33%) patients, 96 (23%) retired and 180 (20.4%) civil servants. No one chose the superior quality private room; 256 (62%) patients used category 3 rooms, 68 (27.2%) of them housewives and 44 (17.2%) retired. The total cost averaged EUR 679.6 +/- 297.90, almost 19 times higher than the minimum monthly salary of civil servants in Togo (EUR 36.30). The total for IS was EUR 428.80 +/- 188.9 and for HS, EUR 935.6 +/- 36.50. The average person in Togo spends EUR 3.99 per person per year on health, while a stroke patient hospitalized in Lome spends an average of 170 times more in only 17.4 days. Accordingly, most of the Togolese cannot access specialized neurology care for a stroke. Drug expenses accounted for the highest portion of the cost, in part because patients are obliged to buy retail pharmaceutical products that could have been provided to them at the hospital. Use of generic drugs could reduce this cost. Length of stay and tests could be reduced by setting time limits for procedures and setting up rehabilitation facilities.

A community-based targeting approach to exempt the worst-off from user fees in Burkina Faso

Background:To contend with the risk of exclusion created by user fees, those implementing the Bamako Initiative (BI) were asked to organise exemption schemes for the indigent. But those exemption schemes...

A process evaluation of user fees abolition for pregnant women and children under five years in two districts in Niger (West Africa).

BackgroundAfrican policy-makers are increasingly considering abolishing user fees as a solution to improve access to health care systems. There is little evidence on this subject in West Africa, and particularly in countries that have organized their healthcare system on the basis of the Bamako Initiative. This article presents a process evaluation of an NGO intervention to abolish user fees in Niger for children under five years and pregnant women.MethodsThe intervention was launched in 2006 in two health districts and 43 health centres. The intervention consisted of abolishing user fees and improving the quality of services (drugs, ambulance, etc.). We carried out a process evaluation in April 2007 using qualitative and quantitative data. Three data collection methods were used: i) individual in-depth interviews (n = 85) and focus groups (n = 8); ii) participant observation in 12 health centres; and iii) self-administered structured questionnaires (n = 51 health staff).ResultsThe population favoured abolition; health officials and local decision-makers were in favour, but they worried about its sustainability. Among health workers, opposition to providing free services was more widespread. The strengths of the process were: a top-down phase of information and raising community awareness; appropriate incentive measures; a good drug supply system; and the organization of a medical evacuation system. The major weaknesses of the process were: the perverse effects of incentive bonuses; the lack of community-based management committees' involvement in the management; the creation of a system running in parallel with the BI system; the lack of action to support the service offer; and the poor coordination of the availability of free services at different levels of the health pyramid. Some unintended outcomes are also documented.ConclusionThe linkages between systems in which some patients pay (Bamako Initiative) and some do not should be carefully considered and organized in accordance with the local reality. For the poorest patients to really benefit, it is essential that, at the same time, the quality of services be improved and mechanisms be put in place to prevent abuses. Much remains to be done to generate knowledge on the processes for abolishing fees in West Africa.

Différences dans la prise en charge de l’asthme associé à la polypose nasosinusienne : cas de deux patients travaillant dans les secteurs privé et informel sénégalais

The recommendations of global initiative for asthma (GINA) do not take into account asthma associated with sinonasal polyposis which in our country remains a frequent entity in spite of its unknown prevalence. Based on two observations made at health facilities, we undertook an analysis of different ways of managing this combination based on the patient's place of residence, his place in the working world, i.e., either a structured or an informal setting, whether or not he had health insurance coverage and the type of health care service he frequents. In our country, the efficient treatment of asthma associated with sinonasal polyposis is hindered by delay in access to health care facilities due to the systematic use of traditional medicine by most patients, by under-equipped medical facilities, for example, lack of spirometry equipment which is available only in public medical facilities and in three private medical entities, the shortage of qualified staff, with only 10 respiratory physicians and four allergists practicing in Dakar, the capital. In the public sector, medical coverage for civil servants is ensured by budgetary charges and public health institutions and by private insurance for workers in the private sector whereas those in the informal sector experience enormous difficulties due to medical expenses in spite of the promotion of mutual health insurance companies. Furthermore, beta-2 mimetics and inhaled corticoids, indispensable for the treatment of asthma, do not appear on the list of essential drugs promoted by the Bamako Initiative which was aimed at making drugs more accessible and less expensive.

Essential drugs in primary health centres of north central Nigeria; where is Bamako initiative?

To assess the availability of essential drugs and the perceptions of clients on drugs situation in the primary health centres of Tafa Local Government Area, north central Nigeria. Checklist consisting of minimum drugs expected in a generic primary health centre developed by the National Primary Health Care Development Agency (NPHCDA) was adopted and used to assess drugs availability, while Focus Group Discussions were conducted to determine the perceptions of clients on drugs situation in the health centres. Results show that, all the 3 primary health centres in Tafa LGA do not implement Bamako initiative (BI) and none was operating Drug Revolving Fund (DRF) system. Out of the minimum recommended score of 54 points for the availability and adequacy of drugs and consumables, New Wuse primary health centre in the LGAheadquarters scored highest points of 19, while New Bwari and Iku primary health centres scored 13 points each. All these are far below the minimum requirement. Similarly, the results of the FGDs confirmed poor availability of drugs and clients dissatisfactions with the drugs situation in the primary health centres. This study has revealed that despite Bamako Initiatives put in place in late 80s essentials drugs are still mirages in many of the primary health care facilities in the study area. It is therefore recommended that, any effort aimed at reforming or repositioning primary health care must take into account resuscitating Bamako Initiative by ensuring functional DRF system in all the primary care facilities.

Expanding access to primary care without additional budgets? A case study from Burkina Faso

The aim of this study is to demonstrate the impact of increased access to primary care on provider costs in the rural health district of Nouna, Burkina Faso. This study question is crucial for health care planning in this district, as other research work shows that the population has a higher need for health care services. From a public health perspective, an increase of utilisation of first-line health facilities would be necessary. However, the governmental budget that is needed to finance improved access was not known. The study is based on data of 2004 of a comprehensive provider cost information system. This database provides us with the actual costs of each primary health care facility (Centre de Santé et de Promotion Sociale, CSPS) in the health district. We determine the fixed and variable costs of each institution and calculate the average cost per service unit rendered in 2004. Based on the cost structure of each CSPS, we calculate the total costs if the demand for health care services increased. We conclude that the total provider costs of primary care (and therefore the governmental budget) would hardly rise if the coverage of the population were increased. This is mainly due to the fact that the highest variable costs are drugs, which are fully paid for by the customers (Bamako Initiative). The majority of other costs are fixed. Consequently, health care reforms that improve access to health care institutions must not fear dramatically increasing the costs of health care services.

“The problem of the worst-off is dealt with after all other issues”: The equity and health policy implementation gap in Burkina Faso

In West Africa, the famous “implementation gap” concept applies to health policies. During the implementation of the Bamako Initiative (BI), the actors were drawn to policies solely for their orientation towards efficiency, thereby neglecting the equity aspects. This paper aims to present an in-depth understanding of this situation, developed through a case study and socio-anthropological fieldwork. The study is informed by a policy framework of analysis that integrates streams theory and the anthropology of development. Multiple sources of data were used: concept mapping (2), in-depth interviews (24), informal interviews (60), focus groups (4), document analysis, and field observation (7 months). The results indicate that the equity aspect of health policies was omitted during training on the use of proceedings from drug sales and user fees; donor agencies and NGOs were more preoccupied with efficiency than equity; the peripheral actors were not driven to ensure that indigents had free access to health care; society was not concerned with the sub-groups of the population; centralized decisions were taken without consultation, remained vague, and were not followed-up; and the concept of equity was perceived differently from those who devised policies.I offer a threefold explanation of why equity was neglected. First, the “windows of opportunity” for achieving equity goals were not seized, at least at the point that led to real change. Second, the policy entrepreneurs did not take on the task of coupling the problem streams with the solutions streams, which is necessary for a successful implementation. Third, the situation of the indigents did not exhibit the necessary characteristics for them to be considered a public problem. For scientific and social reasons it is urgent that we find a solution to halt the exclusion to health care among the poorest groups.

Rapid achievement of the child survival millennium development goal: evidence from the Navrongo experiment in Northern Ghana

To determine the impact of deploying nurses and volunteers to village locations on demographic and health outcomes. We implemented an experimental design that emphasizes the value of aligning community health services with traditional social institutions that organize village life. Data for this analysis come from the Navrongo demographic surveillance system, a longitudinal database that tracks fertility, mortality, and migration events over time. The experiment uses conventional demographic methods for estimating mortality rates from longitudinal demographic surveillance registers. Posting nurses to community locations reduced childhood mortality rates by over half in 3 years and accelerated attainment of the childhood-survival millennium development goal (MDG) in the study areas relative to trends observed in comparison areas. Results from the Navrongo experiment demonstrate that community health and family planning programmes can have an impact on childhood mortality. Posting nurses to communities can dramatically accelerate the pace of progress in achieving the childhood-survival MDGs. Community-volunteer approaches, however, have no additional impact, a finding that challenges the child survival value of international investment in volunteer-based health programmes. The total cost of the intensive arm of the project is less than $10 per capita per year. Navrongo research thus demonstrates affordable means of attaining the child survival MDG agenda with existing technologies.