NATIONAL COMMUNITY-HEALTH INSURANCE AT VILLAGE LEVEL - THE CASE FROM GUINEA-BISSAU

The experience in Guinea Bissau of a voluntary levy scheme at village level, called 'Abota', makes one point very clear. Collective health insurance schemes at village level may be feasible and manageable in rural parts of Africa if the village population is allowed to decide on the amount of money and method of collection and if the government supports the scheme by guaranteeing sufficient drugs, low prices, effective control measures and a village health worker who is officiallly part of the national referral system.Without these conditions, cost-recovery schemes should perhaps be postponed until a continuous and integrated care system can be guaranteed. It should be recognized that the absence of an informal drug market in Guinea Bissau and the relative isolation and small-scaleness of its population have been two important enabling factors for the success of the collective health insurance scheme. Suggestions to introduce similar cost-recovery schemes in other settings therefore need to be analysed with caution. The best that UNICEF and WHO can do at the moment, related to the Bamako Initiative, is to abandon the 'easy and rapid solutions approach' to development and negotiate with national governments for a more equitable and participative approach to improve the health of those that both UN agencies want to serve. Fee-for-service schemes appear the easiest solution to cost recovery, but they are not necessarily the best in the long-term. © 1991 Oxford University Press.