Key websites

Background

The Bamako Initiative

One principal vehicle for implementation of user fees is the Bamako Initiative (BI), adopted by African health ministers in 1987, and aimed primarily at increasing availability of resources for essential drugs. It proposed decentralising health decision making to the district level; establishing a realistic national drug policy; and providing basic essential drugs. The Initiative was promoted by the United Nations Children's Fund (UNICEF) and World Health Organization (WHO), and stressed the need for community and individual self-reliance and participation in planning, organisation, operation and control of primary healthcare, making fullest use of local, national and other available resources.

the Bamako initiative recognised that fees could be a barrier to treatment for low-income districts or households

Accordingly, the BI advocated a combination of financing by users, communities, districts and the central government, depending on the specific circumstances in each country. It stipulated that fees collected from patients should not replace existing health budgets. The community would control locally generated funds with consideration for protecting the poorest.

The BI recognised that fees could be a barrier to treatment for low-income districts or households, and included ways of dealing with this. Charges were supposed to be set at a level which is modest in relation to household income, but which still generates enough income to allow for a proportion of patients not to pay anything. For example in Benin about 30 per cent of patients received services for free. Alternatively, community health committees or the government could subsidise those on low incomes. Preventive care, such as vaccinations, could be given free or heavily subsidised. Charges for less essential but very popular treatments, such as injections, were allowed to be higher than for vital treatments. It was also expected that low-income areas would receive larger government subsidies.

The emphasis of the resolution adopted by African health ministers was on community participation in the financing of health services, through "drug revolving funds" (in which an initial supply of drugs is provided to a community, and proceeds from the sale of these drugs are used to buy further supplies). This emphasis was criticised on various grounds including the negative implications for equity, difficulties in implementation, and increased dependence on UNICEF for financing. In addition, while the BI envisaged various financing mechanisms – including payment for drugs, payment per episode, and pre-payment schemes – the focus of country governments has been on the fee-for-service mechanism, as this is easiest to implement.

It appears that BI programmes enjoyed some success in improving access to drugs and quality care. The Bamako Initiative in West Africa, a World Bank background paper, emphasises the role of community ownership of locally generated resources in securing these improvements. However, some reports suggest the effect on equity may have been less positive. The equity impacts of community financing initiatives in Africa notes that equity was only a minor goal in BI schemes, and a paper on household behaviour and equity in Benin and Guinea stresses the need to design better exemption mechanisms for the most vulnerable. See also papers on the implications of the BI for affordability, cost-effectiveness and efficiency of primary health care in Benin and Guinea; equity in Burkina Faso; and health seeking behaviour in Nigeria.