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Research Article
Forgoing Healthcare Services: Evidence from a Household Survey in Abidjan (Côte d’Ivoire)
Issue:
Volume 11, Issue 2, June 2026
Pages:
49-59
Received:
18 January 2026
Accepted:
27 March 2026
Published:
28 April 2026
Abstract: Background: In Africa, healthcare is generally supported by households. The heavy burden of healthcare on household leaders can lead them to forego care. In this study, we analysed the determinants of healthcare renunciation among household leaders in Abidjan. Methods: This cross-sectional study was carried out from May to July 2019 in "colombie", a neighbourhood of Abidjan (Côte d’Ivoire). Heads of household that had been living there for at least 3 months were randomly selected. Sociodemographic, economic, health status and health care renunciation characteristics were collected. Logistic regression models were used. Results: The sample consisted of 648 heads of household with a mean age of 35.6 ± 8.37 years and a sex ratio (F/M) of 1.59. Almost all of them (97.53%) had given up care at least once. Medical consultations foregone concerned 57.56% of them (including 18.21% to the general practitioner and 39.35% to the specialist). After the consultation, 39.97% of them gave up on other care. People who reported poorer health (OR= 1.93 [1.14–3.29], p=0.015) and those who had no health coverage (OR=6.42 [3.90–11.00], p<0.001) gave up significantly more medical consultations. Heads of households with dependent children (OR=1.93 [1.15–3.34], p=0.015), those who were still in school (OR=1.89 [1.06–3.36, p=0.030]) and those without health insurance (OR=3.30 [1.80–6.19], p<0.001) were significantly more likely to forego postconsultation care. Conclusion: Literacy level, risk perception, health system responsiveness and health insurance coverage were drivers of healthcare renunciation. Health insurance coverage was the factor that most influenced renunciation at different stages of the care pathway. As a large number household leaders don’t benefit from health insurance, this work highlights the need to make health coverage functional in the country.
Abstract: Background: In Africa, healthcare is generally supported by households. The heavy burden of healthcare on household leaders can lead them to forego care. In this study, we analysed the determinants of healthcare renunciation among household leaders in Abidjan. Methods: This cross-sectional study was carried out from May to July 2019 in "colombie", ...
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Review Article
A Scoping Review of Evidence-based Decision-making in Health Financing Reforms: Conceptual Frameworks and Experiences to Inform Health Policy in Cameroon
Issue:
Volume 11, Issue 2, June 2026
Pages:
60-83
Received:
15 April 2026
Accepted:
28 April 2026
Published:
14 May 2026
DOI:
10.11648/j.hep.20261102.12
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Abstract: Evidence-informed decision-making is increasingly recognized as essential for health financing reforms. It can improve effectiveness, equity, and accountability while supporting progress towards Universal Health Coverage (UHC). However, its integration into decision-making to inform health policy processes remains uneven across different contexts. This review aims to synthesise the available knowledge on the use of evidence in health financing decision-making, including international experiences and lessons learned from Cameroon. A scoping review was conducted using the Arksey and O’Malley framework, later refined by Levac et al. Reporting followed the PRISMA-ScR guidelines. Searches were conducted in PubMed, Scopus, and Web of Science, as well as in institutional sources such as WHO and the World Bank. Studies published between 2000 and 2025 in English or French were considered. Eligible studies included empirical and conceptual work on the use of evidence in health financing policies. Data were extracted using a standardized template and analysed thematically. A supplementary analysis of the case of Cameroon was carried out. Twenty-eight studies were included. The use of evidence appears to be multidimensional, encompassing quantitative, qualitative and economic data. Four main types of use were identified: instrumental, conceptual, strategic and interactive. High-income countries showed more institutionalized processes. In contrast, low- and middle-income countries faced fragmented practices, often influenced by external actors. The main determinants include governance structures, stakeholder interests, institutional capacities and the political context. Reforms were generally associated with improved access to care and financial protection, with varying effects on equity and quality. The use of evidence in health financing reforms is progressing but remains uneven. To accelerate progress towards Universal Health Coverage, policymakers should institutionalize evidence-informed decision-making. They should also strengthen national health information and financing data systems, invest in local analytical capacity, and promote transparent multi-stakeholder governance mechanisms. In low- and middle-income settings, reducing dependency on externally driven agendas and aligning reforms with national priorities will be critical to achieving equitable, efficient and sustainable health financing outcomes.
Abstract: Evidence-informed decision-making is increasingly recognized as essential for health financing reforms. It can improve effectiveness, equity, and accountability while supporting progress towards Universal Health Coverage (UHC). However, its integration into decision-making to inform health policy processes remains uneven across different contexts. ...
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Commentary
Improve Population Health and Efficiency Through Internal Competition Within Public Agencies
Issue:
Volume 11, Issue 2, June 2026
Pages:
84-95
Received:
6 March 2026
Accepted:
7 April 2026
Published:
16 May 2026
DOI:
10.11648/j.hep.20261102.13
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Abstract: Against the backdrop of rising federal debt and sweeping workforce reductions across U.S. health agencies under the Trump administration, this commentary proposes a potential principled alternative to arbitrary budget cuts: an intra-agency competition framework to foster internal competition within public health agencies. Drawing on economic theories, the authors argue that splitting agencies into two or more autonomous, competing subunits could help reduce costs, increase efficiency, and improve population health outcomes by channeling competitive incentives toward the public interest. The framework is potentially applicable across three broad functional domains of government: direct service delivery (e.g., the fee-for-service Medicare program), where competing subunits can be evaluated on return on investment weighted by beneficiary satisfaction; regulatory oversight (e.g., the Food and Drug Administration), where competition can reduce bottlenecks and improve decision quality by subjecting each subunit's performance to comparative scrutiny; and public health practice (the Centers for Disease Control and Prevention), where regional subunits can compete on a cost-effectiveness metric such as the ratio of health gains over subunit operating costs. Financial incentive structures permitted under U.S. federal employment law and civil service regulations are discussed. Potential applications in other countries were also explored, especially countries with publicly funded healthcare delivery systems. A potential implementation roadmap is proposed, along with key implementation challenges, including the complexity of measuring outcomes, legal uncertainties regarding executive reorganization authority, political barriers, risks of fragmentation and inequality, and short-term administrative overhead. The paper concludes that rigorous cost-benefit analysis and phased pilot programs are essential before broad adoption.
Abstract: Against the backdrop of rising federal debt and sweeping workforce reductions across U.S. health agencies under the Trump administration, this commentary proposes a potential principled alternative to arbitrary budget cuts: an intra-agency competition framework to foster internal competition within public health agencies. Drawing on economic theori...
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Research Article
Fee Variability and Equity in Primary Health Care Facilities in Benin, 2025
Issue:
Volume 11, Issue 2, June 2026
Pages:
96-110
Received:
19 April 2026
Accepted:
6 May 2026
Published:
21 May 2026
DOI:
10.11648/j.hep.20261102.14
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Abstract: Introduction: In Benin, where out-of-pocket payment constitutes the primary healthcare financing mechanism, the fee-setting practices of First Contact Health Facilities (FCHFs) directly condition financial access to care for the population. This study aims to document the regulatory framework and pricing practices in Beninese FCHFs and to analyse their relationships with the socio-economic characteristics of health districts. Methods: A descriptive and analytical cross-sectional study was conducted in 2025 using fee schedules from 28 of the 34 health districts. Four categories of services were analysed: clinical and technical procedures (n=59), biological laboratory investigations (n=74), medical imaging examinations (n=4), and specialist procedures (n=17, Cotonou only). Tariffs were stratified by area type (urban/rural) and triangulated with departmental poverty rates, FCHF attendance rates, and the share of community-based financing. A Pearson correlation coefficient was calculated between poverty and fee levels. Results: No legal instrument governed FCHF fee-setting. Childbirth exhibited the highest dispersion (CV=94.46%; range: 885–15,000 FCFA). The mean fee for a medical consultation was 1,571 ± 535 FCFA in urban areas versus 1,118 ± 402 FCFA in rural areas, a differential of 40.5%. Certain highly impoverished rural districts maintained fees above the national average. A moderate but statistically significant negative correlation was observed between the departmental poverty rate and the medical consultation fee (r=−0.651; p=0.001). Own revenues of FCHFs accounted for 97.4% of their resources. Conclusion: Fee-setting in Beninese FCHFs relies on informal mechanisms that generate inequities in access to care. The ongoing reforms in the health sector represent an opportunity to establish equitable fee schedules, grounded in the socio-economic realities of the population, the principles of primary health care, and coupled with social protection mechanisms for vulnerable households.
Abstract: Introduction: In Benin, where out-of-pocket payment constitutes the primary healthcare financing mechanism, the fee-setting practices of First Contact Health Facilities (FCHFs) directly condition financial access to care for the population. This study aims to document the regulatory framework and pricing practices in Beninese FCHFs and to analyse t...
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,
Akissi Regine Attia-Konan
