Gilson L, Kalyalya D, Kuchler F, Lake S, Oranga H, Ouendo M
Health Economics and Financing Programme, London School of Hygiene and Tropical Medicine, UK.
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.
尽管巴马科倡议从一开始就卷入了关于任何形式的用户融资可能产生的公平影响的更广泛辩论，但迄今为止，对这种影响的实证研究很少。这项于1994/1995年在贝宁、肯尼亚和赞比亚进行的三国研究，旨在增加相关证据。它不仅试图了解这些国家社区融资活动的公平影响是什么，还试图了解这些影响是如何产生的。因此，它主要通过考虑这些融资活动的设计以及每个国家有限数量的有目的选择的地理区域内不同行为者对其优缺点的看法来调查公平性。关于利用情况的额外数据要么在研究过程中收集（肯尼亚），要么从其他现有研究中获取（贝宁和赞比亚）。这些研究在评估公平性时考虑的关键问题包括实现相对和绝对可承受性收益的程度，以及融资活动的分配和程序正义、决策模式所受到的影响。在各国中，有证据表明贝宁和肯尼亚实现了相对可承受性收益，但肯尼亚的收益没有随着时间的推移而持续，赞比亚没有发现这种收益。此外，没有一个国家通过实施有效的豁免机制来保护最贫困者免受支付负担的问题，或者通过建立有效代表包括最贫困者在内的所有群体利益的社区决策机构来关注绝对可承受性问题。因此，总体而言，尽管贝宁的巴马科倡议计划就其自身的公平目标而言可能被认为是成功的，但其他两个国家的计划即使从这些方面来看也存在明显的公平问题。各国的经验还凸显了一个未解决的问题，即公平是关注最大多数人的最大利益，还是关注促进最弱势群体的利益。
