The Bamako Initiative

by Steve Jarrett

The Bamako Initiative was an African movement, formulated at the WHO Regional Meeting in Bamako, Mali, in September 1987, to refocus and strengthen primary health care (PHC) which was suffering from a lack of resources and implementation strategies. At the time, Africa was facing a deteriorating economic situation due to the debt burden and falling commodity prices, resulting in a declining capacity in health services in spite of strong advocacy from UNICEF for adjustment with a human face for ensuring adequate levels of investment in the health sector. The challenge was to reverse the decline of Government financing and attract money spent out-of-pocket by people in the private sector into the public health system, while promoting additional donor investment. At Bamako, UNICEF proposed tapping community organizations and resources as a new source of funds for strengthening local health services, recognizing that many people were willing to pay for treatment if quality medicines were available and health care provider attitudes were positive. A key driver was to strengthen community-based controls for improving survival and quality of life especially for women and children, making communities as principal partners in health care development.

The Initiative’s key components were 1) the rehabilitation and extensions of the basic health care delivery system; 2) essential medicine supply, 3) appropriate financing of services through fee-for-service, medicine payments or pre-payment schemes, and 4) community mobilization in financing and managing community-based health services. UNICEF set up in HQ in 1988 a Bamako Initiative Management Unit charged with developing and managing UNICEF support to the Initiative. It was clear that a number of management issues needed to be resolved, including national policy development with Ministries of Health, detailed planning of district and community financing and management, motivation of health workers, supply logistics, information management and operations research.

The Unit sponsored three international meetings in 1989 and 1990 aimed at reaching consensus among African experts, development agencies and NGOs on continued political and financial support to PHC, national medicine policies, equity in access to care, decentralized management of community financing and sound management. The Unit worked with over 30 countries in Africa, but also in Asia and the Americas, in assessing readiness for implementing the Initiative. There were distinct approaches taken according to the situation in each country, focusing on decentralization, essential medicine supply or local financing. Most successful were a number of countries in the western region of sub-Saharan Africa. The Unit seconded a researcher from the London School of Hygiene and Tropical Medicine to conduct research and while results were mixed, one study from Cameroon did indicate that user fees with quality service improved access to health care. At the same time, community involvement also determined more accurately those unable to pay for care and found ways to cover for them. As a local chief in Sierra Leone said “the Initiative is all about chickens” as he had to cover fees while receiving chickens in return from those without cash!

It is fair to say that the Initiative stirred up controversy, between the idealists, including a majority of public health experts who were wedded to primary health care being provided free of charge, and the pragmatists who were conscious of the fact that without mobilizing local resources populations would continue to pay considerable sums out of pocket for emergency care as a last resort to treat disease. Quoting the British economist Brian Abel-Smith, “The Poor Cannot Afford Free Health Care” as free health care meant an absence of proper care and subsequent high expenditures on the private market. At the same time, those countries with hierarchical medical systems did not support creating a system of public accountability by local communities in health care provision. In 1996, the Initiative was abandoned by UNICEF.

A quarter of a century later, today, with under-funded health systems still existing in many countries together with falling donor support, access to health care remains problematic. Many lower and middle income countries still rely heavily on out-of-pocket payments, exceeding an estimated 70% of current health expenditure in sub-Saharan Africa for example, which prevent millions of people from accessing basic health services and pushing many into poverty.

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