Bamako Initiative Research Articles

Is paying for health care culturally acceptable in sub-Sahara Africa? Money and tradition

In 1987 UNICEF launched the so-called Bamako Initiative, which has as its main objective to improve the sustainability of primary health care in Africa by making people pay for it. The question is raised whether paying for health care is culturally acceptable in African communities. The author argues that ‘money’ is not a new phenomenon in Africa and that paying for goods and services does not need to conflict with existing traditions of reciprocity in the field of health care. Money is an artifact which is culturally incorporated in a creative manner to satisfy specific needs. Cultural objections to paying for health care, therefore, are unlikely to exist, but how payment should be realised in an effective and just way is another question.

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

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.

Drug supply in Nigeria

The health situation in Nigeria is typical of tropical Africa. It is characterised by high childhood and maternal mortality and a relatively short life expectancy. Mortality in childhood in due mainly to diseases like malaria, measles, poliomyelitis, tetanus, diarrhoea and acute respiratory tract infections. Diseases like filariasis, schistosomiasis and leprosy which are now readily controlled by drugs cause considerable morbidity in later life. Although the technology and tools (particularly vaccines and drugs) for the control of most of these diseases are now available, it has not been possible to make optimal use of them in Nigeria and other tropical African countries because of unfavourable social and economic conditions. The non-availability of drugs most needed for healthcare and disease control has been found to be due not only to insufficient funds but also to the use of the limited funds on expensive drugs that have little bearing on the disease pattern. The Essential Drug Programme initiated by the World, Health Organisation, now adopted by Nigeria and about 100 other countries mostly in the Third World, aims to correct this unsatisfactory drug supply situation by ensuring that the available funds are used to provide those drugs needed by the large majority of the people and are made available at all times at prices that most people can afford. The Bamako Initiative in the African Region of the World Health Organization is also designed to ensure regular availability of drugs particularly to primary healthcare facilities. Seed drugs are provided to the health institutions either by the National Government or through external aid. These are sold to patients at a small profit margin. The proceeds are then used to replenish stocks and the small profit used to improve services in the health centre. The introduction of these programmes in Nigeria has improved drug availability considerably in the past couple of years and should soon start yielding further dividend in the form of measurable improvement in the health situation.

Financing primary health care: An NGO perspective

How is primary health care (PHC) to be funded in a climate of economic recession? The authors survey the financial implications of the Alma Ata Declaration of 1978 and the Bamako Initiative of 1987. They draw on a survey of over 100 Oxfam-funded health projects to assess four methods of PHC funding and their impact on the poorest users: charges for treatment, revolving drugs funds, personal insurance schemes, and income-generating projects.

Ten best readings in … the Bamako Initiative

WHO and UNICEF joined forces to support the Bamako Initiative agreed upon by African ministers of health at a 1987 meeting. Primary health care (PHC) should be advanced by identifying and introducing self-financing mechanisms at the district level (specifically revenue from drug sales) securing a constant supply of drugs and promoting social mobilization. UNICEF has produced several policy papers on recurrent costs and the sales of drugs. The 1988 UNICEF policy paper Problems and Priorities Regarding Current Costs reviews UNICEF practices of financing programs and proposes recommendations. For example about 40% of program expenditure goes to recurrent costs especially the financing of drugs and vaccines. Another 1988 UNICEF working paper is Community Financing Experiences for Local Health Services in Africa which reviews 3 case studies on community financing. Today however UNICEF no longer considers drug cost recovery as essential to the Bamako Initiative. In July 1989 the WHO Regional Office for Africa published Guidelines for the Implementation of the Bamako Initiative. Charging for Drugs in Africa: UNICEFs Bamako Initiative (1989) critiques UNICEFs policy in the context of the IMF and the World Bank adjustment programs. Availability of Pharmaceuticals in sub-Saharan Africa: Roles of Public Private and Church Mission Sectors (1989) highlights the success of cost recovery in church mission health care and the efficiency of distribution through the commercial sector. Its authors consider the Bamako Initiative to be unrealistic. One of the first shots at reviewing community financing experiences is the 1982 article Community Financing of PHC. Other works are Financing PHC Programmes (Christian Medical Commission) Financing PHC: Experiences in Pharmaceutical Cost Recovery (PRITECH) WHOs Financing Essential Drugs and A Price to Pay: The Impact of User Charges in Ashanti-Akim District Ghana.

From Bamako to Kolda: a case study of medicines and the financing of district health services

In 1987 the UN Childrens FUnd and the WHO promoted the Bamako Initiative whose principal objective was to raise funds for primary health care (PHC) at the community level through charging for drug treatment. Although the $180 million (US) requested from donors by UNICEF has not been forthcoming nevertheless about 15 countries in sub-Saharan Africa are at present implementing Bamako-type projects. The management of these projects may benefit from experience in the district of Kolda in Senegal a country in which the principle of self-management of receipts by health service structures has been in force since 1981. In 1985 in the rural district of Kolda Senegal situated 450 km from Dakar the health service was not being used by the population. The district management team attempted to change the pattern of underutilization by rationalizing the mechanisms for financing services and supplies of pharmaceuticals. After the introduction of new forms of management and control the hospital issue of prescriptions for the purchase of drugs at private pharmacies was terminated. The result was an increase in the utilization of services and in receipts which made it possible to increase the stocks held by the pharmacy. It is expected that the services of the pharmacy will be made available to satellite dispensaries giving priority to those which undertake to rationalize their prescribing of medicines and to alter their methods of financing. (authors modified)

The Bamako initiative.

Under the Bamako initiative UNICEF will provide free drugs to participating countries for the 1st few years; drugs will be sold to patients; and communities will control the finances. The aims are to establish a revolving drug fund to pay for future drug supplies and to use leftover money to maintain and improve primary health care services. Several problems with the initiative are foreseen. Firstly charging users may reduce utilization by the poor. Although UNICEF agrees that provision of free service for indigents in necessary systematic identification of these people may be difficult. Secondly financing will be difficult to implement given the rarity of managerial skills and the poor quality of local supervision. The sustainability of the initiative is also in doubt. UNICEF initially proposed large mark ups on the basic cost of the drugs; now partial recovery of the cost is proposed although how charges will be set is unclear. The question of whether services will be dependent when the free drugs stop remains to be answered. A further objection to the scheme is the almost inevitable deterioration of rational prescribing; paying patients will feel justified in demanding drugs and injections. UNICEFs solutions and strategies for implementation of policy remain vague and lack attention to detail. For instance initial training courses aide community management of drug funds but there is no commitment to continued support and local evaluation. Other sources of funding need to be considered. Host governments should commit to continued financial and supervisory input and to maintaining control over their own health services. Communication between staff and government should be established and maintained. Gradual and sensitive introduction with careful monitoring of equity utilization and rational drug use is essential to prevent failure of this important proposal.

Charging for drugs in Africa: UNICEF'S ‘Bamako Initiative’

Charging for drugs in Africa: UNICEF'S ‘Bamako Initiative’

Availability of pharmaceuticals in sub-Saharan Africa: roles of the public, private and church mission sectors.

Although the availability of pharmaceuticals is critical for both curative and preventive health care, drugs are, at best, sporadically available in governmental facilities in sub-Saharan Africa. The religious missions and private sectors are more successful than the public sector in obtaining and distributing drugs. The public sector operates under a myriad of constraints inherent in a bureaucracy; the religious missions have the advantages of better management and access to foreign currency; the private sector is innately efficient. Donor assistance to increase the availability of drugs in the public sector has included support for revolving drug funds, national drug services, the improvement of management techniques, and the local production of pharmaceuticals. None of these interventions has been notably successful. In 1987, UNICEF presented The Bamako Initiative--a proposal to launch an internationally-financed fund for essential drugs for sub-Saharan Africa. However, the proposal is unrealistic in anticipating that the requisite resources and/or hard currency can be raised to support the proposal. As the private sector is a more efficient distributor, it is recommended that the private sector be given responsibility for the distribution of drugs. Nonetheless, some governmental controls will be necessary to ensure that essential drugs are available at the least cost to the consumer.

THE BAMAKO INITIATIVE

The deteriorating economic situation and structural adjustment policies in many sub-Saharan African countries have contributed to the decline in spending upon social services especially upon health. The Bamako Initiative was launched in 1987 in the capital of Mali by the health ministers of African countries at a conference sponsored by UNICEF and the World Health Organization with the goal of ensuring that entire populations would have access to good quality primary health care at affordable prices. The initiative is based upon the following principles: public participation in decision-making contributions by users to finance health centers state participation to ensure that the whole population has access to a minimum package of services and the rational and decentralized implementation of programs at the district health system level. The most dramatic result of applying the principles is the increased use of preventive and curative services. The steady growth in immunization coverage in countries or districts which have applied the principles of the initiative has led to a major reduction in the diseases concerned.