The equity impacts of community financing activities in three African countries

Int J Health Plann Manage. 2000 Oct-Dec;15(4):291-317. doi: 10.1002/hpm.599.


Although the Bamako Initiative from its very beginning was caught up in wider debates about the potential equity impact of any form of user financing, to date there has been little empirical investigation of this impact. This three-country study, undertaken in Benin, Kenya and Zambia in 1994/95, was initiated to add to the body of relevant evidence. It sought to understand not only what had been the equity impacts of community financing activities in these countries but also how they had been brought about. As a result, it investigated equity primarily through consideration of the design of these financing activities and through the perceptions of different actors, within a limited number of purposively selected geographical areas in each country, about their strengths and weaknesses. Additional data on utilization were either collected during the course of the study (Kenya) or drawn from other available studies (Benin and Zambia). Key issues considered in the studies' assessment of equity were the extent to which both relative and absolute affordability gains were achieved, as well as as an influence over both the distributional and procedural justice of the financing activities, the pattern of decision-making. Across countries there was evidence of relative affordability gains in Benin and Kenya, but Kenyan gains were not sustained over time and no such gains were identified in Zambia. In addition, no country had given attention either to the issue of absolute affordability, through the implementation of effective exemption mechanisms to protect the poorest from the burden of payment, or to the establishment of community decision-making bodies that effectively represented the interests of all groups including the poorest. Overall, therefore, although the Benin Bamako Initiative programme might be judged as successful in terms of what appear to be its own equity objectives, the other two countries' schemes had clear equity problems even in these terms. The experience across countries also highlights the unresolved question of whether equity is concerned with the greatest good for the greatest number or with promoting the interests of the most disadvantaged.

Publication types

  • Comparative Study
  • Evaluation Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Benin
  • Community Health Services / economics*
  • Community Health Services / organization & administration
  • Community Health Services / statistics & numerical data
  • Community Participation
  • Cost Sharing
  • Data Collection
  • Decision Making, Organizational
  • Fees and Charges*
  • Financing, Organized / organization & administration*
  • Health Plan Implementation
  • Health Services Accessibility / economics*
  • Humans
  • Kenya
  • Poverty
  • Program Evaluation
  • Quality Assurance, Health Care
  • Social Justice
  • Socioeconomic Factors*
  • Zambia