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The advocacy against monopolies and centralised distribution of inputs such as essential drugs became stronger during the last years in the PBF community. Governments should not maintain one central medical stores distribution system but stimulate the private sector also to enter the market. Yet, this competition should be well regulated to ensure the quality of the products. Monopolies tend to create shortages, a lack of consumer friendliness and the inefficient use of public resources.

Another fierce debate takes place around the wisdom of generalised free health care. It is extremely expensive and tends to lead to poor quality services. When proposing free services the question should be answered where to obtain sufficient (financial) resources. Microeconomic theory explains that ceiling prices for goods or services below the market price lead to black market effects, a non motivated workforce and consumer unfriendliness.

Another debate takes place around PBF and equity. When there are sufficient resources, PBF can be effective to assist the vulnerable through the equity instruments of targeting with additional subsidies vulnerable regions, health facilities and individuals.

Nobody likes to pay user fees or insurance premiums but they are in most countries necessary to ensure sufficient resources for quality health services. Households should contribute proportional to their income and this proportion may be set at around 8-12%. In low and low-middle income countries the most efficient manner is to set user fee and premium prices at health facility level. Yet, at the same time Safety nets should be put into place to protect the vulnerable. The proportion of vulnerable may vary dependant on the available public resources. In Cameroon we have set this at 10% but in the Central African Republic at a higher proportion of 20% because of the higher poverty level.

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