For decades, the Ivorian health system has strengthened social and economic inequalities. This is because the country had the ambition (mainly pursued in more affluent times) of establishing a health system based on the French model; however, the latter’s patterns of hospital organization and university training were not modified in the slightest, and the system was weighed down by a bureaucratic and corporative spirit. The concentration of equipment and qualified personnel in Abidjan, the state of neglect of the rural health units, the disorganization reigning in the PSP until very recent years, and the preponderance of professional and commercial interests in the formulation of health policies (e.g. as regards supplies of pharmaceutical products) have led to some very obvious repercussions: Côte d’Ivoire has a per capita GNP three times larger than those of its neighbors in the Sahel, but its health indicators are scarcely any better than theirs.
Because of these structural shortcomings, the public finances allocated to health benefit the rich more than the poor. By combining the standard-of-living study’s findings regarding the use of health services with a detailed study of the applications of government subsidies, a recent study reached the conclusion that: "... per capita health subsidies in rural areas are 34% lower than they are in urban areas, [...] the subsidy going to the poorest quintile is 64% lower than that received by the upper quintile." ([9] page 11.) In other words, in Côte d’Ivoire -- as in other countries -- using health services is a way of obtaining government assistance, but (and this is a comparatively original feature) nowadays in Côte d’Ivoire the rich receive more of this assistance than the poor. This is because the poorest patients hardly use anything but the first level of care, whereas the Government provides very generous subsidies for the tertiary level, which in practice serves the richest patients. Consequently, public-sector health care in Côte d’Ivoire is a mechanism for reverse wealth redistribution (another one -- albeit to a lesser extent -- being education; see [9]).
It should also be noted, for example, that average per capita spending on modern drugs differs by a ratio of 1:60 between the first and tenth deciles in the breakdown of total per capita consumer spending, and that the spread is very much larger in the case of consultations (1:300), and is enormous (contrary to all expectations) in the case of expenditures on hospitalization (1:3,000!). There is an absolutely extraordinary degree of injustice, therefore, in the use of modern health-care systems, as illustrated in the following chart (showing total household expenditures on health, together with spending on traditional medicine and modern medicine). This should certainly provide food for thought for health specialists.
Source : 1993 Household Survey (INS)
The Initiative is, therefore, fundamentally unjust, at least in the case of Côte d’Ivoire; however, it will be favorably received because it will make the international organizations feel good, because it will allow the country to receive assistance, and because the country’s population is used to having an unjust health system. Nevertheless, given that the Initiative inevitably raises the questions of what the priorities in the health system should be and what criteria should be applied when selecting the patients to benefit from the available resources, while at the same time making it necessary to define the roles of the State and civil society (private enterprises, households, and associations or other nonprofit organizations), it is clearly a step in the right direction; i.e. toward control of the health system by nonspecialists.
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