Ensuring equal access to basic health services: To pay or not to pay?

Can cost recovery and performance-based financing support the development of inclusive health systems in the Central African Republic and other fragile countries?

Highlighting the positive impact of EU actions in the health sector in the Central African Republic (CAR), speakers will engage in a lively debate around user fees and the provision of health services in post-crisis CAR and other countries. A link with the development and implementation of Performance-Based Financing in fragile contexts will also be established. Representatives from CAR, national authorities, international NGOs and the donor community will exchange their expectations and concerns about the Cost Recovery Mechanism, while considering their complementary role to build inclusive health systems that cater to the needs of the most vulnerable. The session will take place in French.

Key points

  • Even low fees deter patients from seeking care when their health deteriorates.
  • Universal access to free healthcare has been introduced in a number of African countries.
  • Further reforms are planned in the Central African Republic, which remains in a state of crisis.
  • Equitable healthcare means provision of care is ensured based on need.
  • Healthcare systems risk remaining underfunded.


The Central African Republic is still in a state of conflict and requires humanitarian assistance. With a quarter of the population displaced, most services are supplied through emergency aid and nutritional support. There are plans to build up a system with free healthcare for all, but there are considerable challenges in terms of funding and management. The future system is at risk of underfunding unless more public revenue is generated through measures such as more systematic tax collection. The new system must also provide for efficient distribution of both pharmaceutical products and supplies. There is a broad understanding that the most disadvantaged groups of the population should benefit from free healthcare, even if care were not to be free for all. Maternal healthcare is a priority and combined with free clinical care for children under the age of five, it is a measure that has proven successful in other countries and would be favoured by the Central African Republic’s current government. If user fees were to be determined based on income in a country with a great deal of instability, only very few would be able to meet the cost. As the state of emergency in the Central African Republic has dragged on, large parts of the population would be considered vulnerable. Public registers are insufficient and parts of the population do not possess any identification. Universal and free access to healthcare would require commitment by donor countries and healthcare partners alike. Experience in neighbouring countries has shown that control functions are indispensable; performance-based financing could be established in a fragile country based on indicators and external verification of costs to prevent misallocation, even if audit systems add to the management cost. As long as the country remains in conflict and a state of emergency that leads to a higher rate of mortality due to armed violence, any healthcare measures must be accompanied by better civil protection and access to education. In the wake of the country’s transition from a state of emergency towards assuming a development agenda, the EU’s Humanitarian Aid Operations (ECHO) continues to provide a mobile response to meet both nutrition and health needs. The EU contributes to the reform of the healthcare system in CAR, both by providing training and structural planning. Improved healthcare also requires complementary systems such as improved sanitation and transport infrastructure. Even for a healthcare system with only minimum coverage, the need for funding and international assistance is considerable. Universal healthcare coverage in CAR would not be achieved only by domestic funding. Donors would expect domestic revenue to provide the basic funding for the future healthcare system, even if it were partially free for most patients.


Levels of infant mortality in the Central African Republic are alarming due to the protracted armed conflict. There is a dire need to address the situation of maternal and early childhood health in the reform of the healthcare system.

Organised by


Francesca Di Mauro
Head of Unit (Central Africa), Acting Director (Central & Southern Africa, Indian Ocean)
European Commission
Androulla Kaminara
Director for Sub-Saharan Africa, Asia, Latin America and Pacific
European Commission - DG for Civil Protection and Humanitarian Operation
Christophe Lemiere
Human Development - Program Leader - Sahel
World Bank Group
Marie Philips
Health Policy Advisor
Médecins Sans Frontières
Nicolas Gonze
Team Leader Central Africa