[Financing healthcare in low-income countries: recurring questions, new challenges]. / Financement de la santé dans les pays à faible revenu: questions récurrentes, nouveaux défis.

Healthcare financing policies in low-income countries have gone through three successive phases. In the first phase the dominant approach was based on free access to healthcare and focused first on development of vertical programs and then on the necessity of providing primary care to all. While maintaining the emphasis on accessibility to primary care, the second policy phase introduced user fees and attempted to integrate healthcare programs into district-based healthcare structures. The third phase has been strongly influenced by the relationship between healthcare and development and the Millenium Objectives and places strong emphasis on necessity of developing insurance schemes. Recent studies on the relationship between healthcare spending and health status indicate that the efficiency and effectiveness of healthcare spending plays a more determinant role than the amount. At the same time an effort is being made to develop synergy between the different players in the health care systems and to clarify the role of each player by hinging financing decisions on operating criteria such as "public welfare", externalities, catastrophic costs, and equity. Although many countries have made significant progress, there are still several lagging areas, i.e., coverage for the poorest segment of the population (despite the rhetoric), follow-up of financing, and governance. Increasing external aid already initiated by several states may have a non-negligible impact on the macroeconomic balance. Since these changes could lead to adverse effects on health, there is a need to implement careful non-dogmatic policies.

[A future path toward cooperation: hospital partnership]. / Une voie d'avenir pour la coopération: le partenariat hospitalier.

Development agencies have been promoting hospital programs in developing countries for several years. Although they have placed the accent on reorganising the management of these hospitals, most funds have been used for investment in buildings and equipment. This policy has failed, for several reasons. In many cases the field of intervention is too narrow, and involved too few professionals. There is also an erroneous belief that management restructuring can solve all the problems of running an hospital. Indeed, practitioners themselves, who are the cutting edge, are often ignored. Many projects are started without evaluating the resources of the hospital team. And a training program is not always the best solution when there is a lack of motivation or poor basic knowledge. Development agencies are often simply regarded a funding sources, yet money is not the answer to all hospital problems. Clearly development agencies cannot enter partnerships directly with hospitals in developing countries, but the solution may be to get these hospital more involved. For example, French hospitals are legally authorized to undertake international cooperation programs, free from time limits and political pressures, contrary to development agencies. What is more, hospitals in the developed countries can learn much about cost rationalization from their counterparts in the developing countries. Development agencies should thus encourage this sort of hospital "twinning" initiative and provide financial support, but it is important that the hospitals involved should be fully independent to avoid excessive bureaucracy.

Experience de recouvrement des couts medicamenteux au CHNSS; Burkina-Faso

En Afrique au Sud du Sahara; les services de sante souffrent d'une baisse constante des budgets alloues. Les ministres de la sante de la region africaine ont adopte en 1987; sous l'egide de l'OMS; une strategie de recouvrement des couts au niveau du district sanitaire; appelee initiative de Bamako. Le probleme du financement des prestations au niveau des hopitaux reste a resoudre. Une experience de recouvrement des couts medicamenteux est menee dans le service de pediatrie du Centre Hospitalier National Souro Sanou de Bobo-Dioulasso (Burkina-Faso) depuis novembre 1989; a partir d'un stock de medicaments fournis par l'UNICEF