To contend with the risk of exclusion created by user fees, those implementing the Bamako Initiative (BI) were asked to organize exemption schemes for the indigents. But that exemption schemes was never put in place in Africa due to the difficulty of identifying indigents. An action research has been implemented whose objective was to test the hypothesis that a community-based process for selecting beneficiaries of user-fee exemptions in an African environment of BI organization is feasible.
This study was carried out in 10 of a rural district’s 25 primary health centre in Burkina Faso. Village selection committees (VSC) made lists of worst-off. A process evaluation was implemented through documentation analysis, accounting calculation, focus group and in-depth interviews.
The 124 VSCs selected 566 persons. The 10 local commitees retained 269 persons (48%), i.e. 2.81 per 1,000 inhabitants. The annual profits thanks to the user fees schemes could support on average 6 times more indigents than the mean number selected by the VSCs. The action was well received by the stakeholders.
In the rural African context, villagers are capable of selecting those who should be exempted from user fees according to their own perspective. Health centres have a certain financial capacity to take care of indigents. In a community-based targeting approach using endogenous resources generated from BI profits, local perceptions of the health centres’ financial viability, coupled with the hierarchical social context, led to a very restrictive selection of candidates for exemption.