… and revenues have been applied with weak public accountability

Mechanisms to offset some of these effects have generally included requirements for increased local decision-making and public participation.

For example, decisions have been localized at community level on:

  • what level of fees should be charged;
  • how exemption should be managed;
  • retaining fees locally to improve quality of care;
  • encouraging local participation in fee management;
  • ensuring that additional revenues raised are earmarked for primary care services (Wang'ombe, 1997).

This has often been done, however, without taking the additional step of ensuring that local-level decision-making is not simply dominated by local elites or by hospital-based personnel who monopolize these resources within hospital services (Loewenson, 2000b).


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Involvement in health

"Community participation"

Financing health systems

Use of resources
Interactive exercise