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By R. Paul Shaw, Martha Ainsworth

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The remaining two-thirds emphasize improvements in primary health services such as staff incentives or drug availability, as the primary objective of user fees. Many countries in this group -- particularly the Francophone countries -- participate in the "Bamako Initiative". A major objective of the Bamako Initiative is to employ cost-sharing to improve primary health care services. 3 Caution needs to be exercised when interpreting the contribution of user fee revenues to the operating or recurrent costs of health facilities.

Nurturing such insurance offers previously unexpected opportunities to develop better health care systems in Sub-Saharan Africa. Page x ACKNOWLEDGEMENTS Assistance and helpful comments on this volume have been provided by many people, acknowledged at the conclusion of each individually authored chapter. In particular, the editors express thanks to A. Edward Elmendorf, Kelly Hallman, Jeffry Hammer, Ishrat Z. Husain, Larry Forgy, William McGreevey, Germano Mwabu, Marie-Odile Waty, and Annemarie Wouters.

Either of these two problems can ruin the long-run viability of a self-financing insurance scheme. Although experience with self-financing health insurance is limited across much of Sub-Saharan Africa, experience is growing and there are lessons to be learned from ongoing and past efforts. Chapter 9 describes the design, management and operational efficiency of four health insurance programs in rural and urban Zaire, a country where government health services are already largely financed through user fees.

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