Table 4.

Synthesis of pressures mentioned in the literature (1988 to 2009)

Health system functions	Pressures on the health system
Service provision	Increase in service utilization and in the demand for services
Health personnel	Increase in workload, increase in the patient/provider ratio, insufficient medical staff
	Loss of income
	Lack of time for consultations
	Feeling of being exploited, frustrated, overworked
	Negative attitude of providers
	Deterioration in staff morale
Health information	Lack of information on the number and type of services carried out in the health centres and on the amount of reimbursements.
Drugs and vaccines	Problems of availability of drugs
	Insufficient drugs and kits to meet local needs
	Delays and under-distribution of consumables
Funding	Funding unpredictable, insufficient and discontinuous
	Loss of income for health centres and increased debt
	Problems with reimbursements for cases of referrals
	Reverting back to charging for services and drugs
	Insufficient funding
	Service providers having difficulty paying recurrent expenses
	Delays in reimbursements
Governance and leadership	Poor planning and communication; poor understanding of the policies
	Inadequate supervision
	“No blame” game and problems in obtaining accounting reports and in assigning responsibilities for acts
	Complexity of funding procedures
	Interference with other health policies and programs