Community financing or cost recovery: empowerment or social dumping?

Community-directed treatment with ivermectin in two Nigerian communities: an analysis of first year start-up processes, costs and consequences

OBJECTIVES

To determine the start-up processes, costs and consequences of community-directed treatment with ivermectin (CDTI) in two onchocerciasis endemic rural towns of Southeast Nigeria; namely Achi and Nike. The other objectives were to discover the community-financing mechanisms, local ivermectin distribution strategies and communities' organisational capacity to handle the programme.

METHODS

Structured questionnaires, informal interviews, observations, discussions with community members at general village assemblies and community outreach lectures were used at different stages of the study.

RESULT

The towns had the organisational capacity to implement the programme. Coverage with ivermectin was between 31-73% in Achi (mean = 58.6%), and 36.6-72% in Nike (mean = 61.95%). The unit financial costs were $0.17 in Nike and $0.13 in Achi, but the unit aggregate cost was $0.37 in Nike and $0.39 in Achi. When research costs were removed, the unit aggregate cost was $0.22 in Achi and $0.20 in Nike. Provider's financial costs and communities' non-financial costs were the biggest contributors to the aggregate cost. The cost would decrease in subsequent years since the research cost and parts of the mobilisation and training costs would not be incurred after the first year.

CONCLUSION

Governments and sponsors of CDTI should find means of continuously strengthening the programme and providing technical support to the communities. As both CDTI and communities are dynamic entities, continuous health education campaigns are needed to keep reminding the people of the benefit of long-term ivermectin distribution, together with the need for community ownership of the programme.

The potential for social mobilisation in Bangladesh: the organisation and functioning of two health insurance schemes

Health insurance schemes are usually assessed according to technical indicators. This approach, however, neglects the dynamic perspective of insurance schemes as an element of people's mobilisation for participation in organising and managing health care delivery and financing. The first part of this paper describes the technical performance and the level of community involvement in management of the two largest health insurance schemes in Bangladesh, both in the rural areas and in the non-government sector. Part two discusses these achievements in light of the schemes' potential role as a mechanism for people's management of health care. A review of documents and key-informant interviews were conducted. Key findings include that (1) subscribers currently are not actively participating in scheme management. However, existing family groups, involved in credit programmes may serve as entry-points for interaction. This is sustained by the 'natural link' between health insurance as a means of spreading the risks of treatment costs and credit programmes as a means of decreasing the relative impact of illness on household income. (2) The schemes' role could be further enhanced, by improving their technical performance and applying health care systems elements with the input of all partners involved. These issues are avoidance of service duplication with other providers; better protection of the poorer households; inclusion of hospital care in the coverage package; simplification of scheme administration by introduction of episode-based co-payments instead of the current itemised ones and concentrating the schemes at the level of community-based services, which may be self-financed and also self-managed by the community, given available sensitisation, training and interaction. A shift to episode-based co-payments would also introduce solidarity among patients and among individuals at higher risk, such as pregnant women and under-fives. Finally, action-research is needed to document the process of increased community involvement.

Utilisation rates and expenditure for public and private, curative-care services in semi-urban Guatemala

In November 1994, a retrospective survey was conducted for two purposes; to investigate patterns of health-care uptake for childhood and maternal illness in semi-urban Guatemala; and to gain an insight into the expenditure incurred by the subjects when they consulted the various health-care providers. The subjects, who all belonged to a semi-urban ladina community, had easy geographical access to the health-care providers, of all types, operating in Sacatepequez, in the central highlands of Guatemala. The community was divided into clusters of roughly equal population size and 20 of these were selected. Within each selected cluster, eight households that had at least one young child (< 5 years of age) were investigated. Mothers belonging to each household were asked whether, how frequently, and where they had sought outside help for any health problem that had possibly affected them or their children during the past year. Subsequently, they were also invited to recall the expenditure incurred on the last visit, if any, to each type of health-care provider established in the area. The crude utilisation rates, for all providers combined, were 1.0/women.year and 0.8/child.year. Overall, 61% of women had no uptake of curative care for themselves and 12% of families no such uptake for their children. Lay curers and clinics run by non-governmental organizations were hardly utilised. Drug vendors accounted for 38% of contacts by women and 26% by children, private physicians for 34% and 38%, and public services for 22% and 33%, respectively. The utilisation rate of the official sector attained roughly 0.3/person.year in both women and children. Dissatisfaction with the treatment received and the lack of drugs were often given as reasons for not attending public services. The median total expenditure incurred per curative, health-care contact ranged from 0 quetzales in the official health centres to 63 quetzales with private physicians (a U.S.$ being equivalent to 5.5 quetzales at the time of the study). Although for each type of provider (except the health centres), expenditure was nearly equal for a woman or for a child contact, it consisted of a different mix of cost elements (consultation fee, drugs and transport) for each of the various categories of provider. The willingness for a more prominent role of the public sector. It would seem that there is, in the socio-economic environment of semi-urban Sacatepequez, room for experimenting with alternative modes of health-care financing to increase the quality and attractiveness of public services and their utilisation.