Strengthening health services for MCH in Africa: the first four years of the ‘Bamako Initiative’

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The basic intent of the Bamako Initiative which is supported by African Ministers of Health WHO and UNICEF was to provide longterm sustainability of primary health care (PHC) by strengthening community mobilization and using community resources and strengthening district level health services. National government would focus on the referral system. Consideration in this article is given to important issues that have arisen since its inception in 1987 the policy framework key components the global action country progress (Benin Guinea Kenya Nigeria Sierra Leone Togo Mali and Zaire) key management questions and future directions in the next decade. The Bamako Initiative has 4 key features: 1) the rehabilitation and extension of the basic health care delivery system particularly for maternal and child health services and including peripheral health facilities and the network of community health workers; 2) provision for affordable drugs and improved knowledge on prescribing and use; 3) appropriate financing of services for longterm sustainability; and 4) community mobilization in order to increase the effectiveness and esteem of health services and involving the community as a full partner in the decision making process. The Ministers agreed to 8 principles which would facilitate the implementation of the Bamako Initiative in September 1988 as follows: 1) national commitment to the development of universally accessible PHC services 2) essential drug policies in agreement with the development of PHC 3) community financing which is consistent at all levels of care for health care services 4) substantial government financial support 5) substantial decentralization to the district level for management of PHC 6) decentralized management of community resources 7) measures which ensure access of the poor for PHC and 8) clearly defined intermediate objectives and agreement on indicators to evaluate the effectiveness. A number of issues have arisen concerning the implementation of the Initiative such as community control equity drug use and the low status of health workers. Since 1988 UNICEF has established funding for national task forces and conducted 3 conferences to deal with the issues and constraints. Collaboration is important and considerable involvement has been effected by the World Bank the African Development Bank and multilateral bilateral and government agencies. The most active supporter of the Initiative has been Nigeria. Key lessons are that there is a need for policy development for support from national and local leaders for a supportive legal system for detailed planning for logistics strategies and workable management for information management for operations research and for balanced implementation in rural and urban areas. International solidarity is need to provide the resources to fulfill the aims.