Mutual health organizations (MHOs) are voluntary membership organizations providing health insurance services to their members. MHOs aim to increase access to health care by reducing out-of-pocket payments faced by households. We used multiple regression analysis of household survey data from Ghana, Mali and Senegal to investigate the determinants of enrolment in MHOs, and the impact of MHO membership on use of health care services and on out-of-pocket health care expenditures for outpatient care and hospitalization. We found strong evidence that households headed by women are more likely to enrol in MHOs than households headed by men. Education of the household head is positively associated with MHO enrolment. The evidence on the association between household economic status and MHO enrolment indicates that individuals from the richest quintiles are more likely to be enrolled than anyone else. We did not find evidence that individuals from the poorest quintiles tend to be excluded from MHOs. MHO members are more likely to seek formal health care in Ghana and Mali, although this result was not confirmed in Senegal. While our evidence on whether MHO membership is associated with higher probability of hospitalization is inconclusive, we find that MHO membership offers protection against the potentially catastrophic expenditures related to hospitalization. However, MHO membership does not appear to have a significant effect on out-of-pocket expenditures for curative outpatient care.

The authors examine accessibility and the sustainability of quality health care in a rural setting under two alternative cost recovery methods, a fee-for-service method and a type of social financing (risk-sharing) strategy based on an annual tax+fee-for-service. Both methods were accompanied by similar interventions aimed at improving the quality of primary health services. Based on pilot tests of cost recovery in the non-hospital sector in Niger, the article presents results from baseline and final survey data, as well as from facility utilization, cost, and revenue data collected in two test districts and a control district. Cost recovery accompanied by quality improvements increases equity and access to health care and the type of cost recovery method used can make a difference. In Niger, higher access for women, children, and the poor resulted from the tax+fee method, than from the pure fee-for-service method. Moreover, revenue generation per capita under the tax+fee method was two times higher than under the fee-for-service method, suggesting that the prospects of sustainability were better under the social financing strategy. However, sustainability under cost recovery and improved quality depends as much on policy measures aimed at cost containment, particularly for drugs, as on specific cost recovery methods.

Ensuring financial access to health services is a critical challenge for poor countries if they are to reach the health Millennium Development Goals (MDGs). This article examines the case of Rwanda, a country which has championed innovative health care financing policies. Between 2000 and 2007, Rwanda has improved financial access for the poor, increased utilization of health services and reduced out-of-pocket payments for health care. Poor groups' utilization has increased for all health services, sometimes dramatically. Use of assisted deliveries, for example, increased from 12.1% to 42.7% among the poorest quintile; payments at the point of delivery have also been reduced; and catastrophic expenditures have declined. Part of these achievements is likely linked to innovative health financing policies, particularly the expansion of micro-insurance ('mutuelles') and performance-based financing. The paper concludes that the Rwanda experience provides a useful example of effective implementation of policies that reduce the financial barrier to health services, hereby contributing to the health MDGs. Today's main challenge is to build the sustainability of this system. Finally, the paper proposes a simple set of rigorous metrics to assess the impact of health financing policies and calls for implementing rigorous impact evaluation of health care financing policies in low-income countries.

Attaining efficiency in a health care system with a budget constraint involves increasing the utilization of the most cost-effective services. This can be achieved by adjustments to prices, cost curves, or demand curves. In this paper, the potential for demand curve adjustments is examined by selecting two apparently cost-effective services (prenatal care and childhood immunization against tuberculosis), and analyzing the factors explaining their utilization. Data from recent household surveys in Burkina Faso and Niger are used. A multivariate analysis of utilization employs income, price, and taste variables. Utilization is highly sensitive to the distance which must be travelled to the health facility, a price, and taste variables. Utilization is highly sensitive to the distance which must be travelled to the health facility, a price variable. Members of certain ethnic groups tend to use the services less, other things being equal. The importance of demand-side factors like ethnicity points to certain kinds of policy interventions like information, education and communication activities which could increase the utilization of cost-effective services.

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The objective of this paper could be phrased as follows: What are the health consequences of changes in public fiscal and income policies? This is an important question, especially in times where programmes of macroeconomic structural adjustments are being implemented in many developing countries. The health consequences of these policies continue to be debated. Some argue that the main victims are mainly the poor and the vulnerable [cf. Cornia et al. (1987) and (1988)]. Others maintain that the longer term benefits will more than compensate for short-term losses and that the real test is to compare with the consequences of not making the adjustments. The conceptual and empirical foundation of the debate seems to be less than satisfactory, however. It is our view that to understand the health consequences of such policies a careful examination of three issues are required: (a) the existing pattern of disease; (b) the initial distributional structure (equity pattern) of public policies; and (c) the behavioural response of households in allocating resources towards health-promoting activities given (a) and (b). Our approach is necessarily context specific. It is in line with Streeten's (1988) conclusion that ..... the most important general lesson that emerged was that there are no general lessons, and that each case has to be treated separately and on its merits". Our purpose is to provide an overall general framework that serves as a guide to examine specific cases. For more detailed theoretical analysis, see Diop (1990), and for an empirical application, see Diop and Sirageldin (1990).