Gilson L
University of Witwatersrand, South Africa.
Health Policy Plan. 1997 Dec;12(4):273-85. doi: 10.1093/oxfordjournals.heapol.a018882.
This paper reviews the experience of implementing user fees in Africa. It describes the two main approaches to implementing user fees that have been applied in African countries, the standard and the Bamako Initiative models, and their common objectives. It summarizes the evidence concerning the impact of fees on equity, efficiency and system sustainability (as opposed to financial sustainability), and the key bottlenecks to their effective implementation. On the basis of this evidence it then draws out three main sets of lessons, focusing on: where and when to implement fees; how to enhance the impact of fees on their objectives; and how to strengthen the process of implementation. If introduced by themselves, fees are unlikely to achieve equity, efficiency or sustainability objectives. They should, therefore, be seen as only one element in a broader health care financing package that should include some form of risk-sharing. This financing package is important in limiting the potential equity dangers clearly associated with fees. There is a greater potential role for fees within hospitals rather than primary facilities. Achievement of equity, efficiency and, in particular, sustainability will also require the implementation of complementary interventions to develop the skills, systems and mechanisms of accountability critical to ensure effective implementation. Finally, the process of policy development and implementation is itself an important influence over effective implementation.
本文回顾了非洲实施使用者付费的经验。它描述了非洲国家采用的实施使用者付费的两种主要方法，即标准模式和巴马科倡议模式，以及它们的共同目标。它总结了有关费用对公平、效率和系统可持续性（与财务可持续性相对）影响的证据，以及有效实施这些费用的关键瓶颈。基于这些证据，本文进而得出三组主要经验教训，重点关注：在何处以及何时实施费用；如何增强费用对其目标的影响；以及如何加强实施过程。如果单独引入，费用不太可能实现公平、效率或可持续性目标。因此，应将其视为更广泛的医疗保健筹资方案中的一个要素，该方案应包括某种形式的风险分担。这种筹资方案对于限制与费用明显相关的潜在公平风险很重要。费用在医院中的潜在作用大于在初级设施中的作用。实现公平、效率，特别是可持续性还需要实施补充干预措施，以发展对确保有效实施至关重要的技能、系统和问责机制。最后，政策制定和实施过程本身对有效实施有重要影响。
