Monday, April 15, 2013

The Bamako Initiative - Wrong Medicine for Wrong Ailment By Abimbola Lagunju

Sometime in 1987, at a gathering in Bamako, Mali under the auspices of Unicef and the World Health Organization, African Ministers of Health, browbeaten by IMF and other lending institutions into cutting government expenditure on social services, agreed to reduce the budgetary “burden” costs of provision of healthcare for their population by introducing user-fee payment for healthcare at all levels of service delivery. Known as the Bamako Initiative, the scheme was structured to make money for the government to finance health budgets through profits made from sale of healthcare services and drugs to the population. The intention of the promoters was not stated this way; it came in the guise of decentralization, community empowerment, health worker motivation and a host of other breezy phrases, but with a single goal of making people pay for services.

There were two major things wrong with this Initiative right from onset. Firstly, the scheme assumed that the modern healthcare system had the complete trust of the population and thus, the population would conform themselves to the new change whatever the costs. Everyone involved in this initiative either forgot or was oblivious of the fact that many of the signatory-countries to this initiative were either passing through or had just passed through socio-political upheavals including wars, coups and general instability which had left many infrastructures and services either destroyed or ineffective. In other words, the health system had never been at its best and had never really had the time to build a relationship of trust with the people.

Secondly, the scheme assumed that people had money and would pay if the services were good. And this was during a period when the Structural Adjustment Program of the IMF had not only decimated the middle class, but had also impoverished the poor rural population beyond the limits of any memorable time in history. It caught the people by surprise and alienated them from the public health service. Thus, the introduction of user-fee payment for health services wedged a barrier between the health system and the population it was meant to serve. It divided the population into dependables, i.e. those who could pay for services and the expendables, i.e. those who paid with their lives.

The impoverishment of the middle class through the devaluation of national currencies directly affected the health service providers as well. Their salaries could not meet their needs. The health professionals left the shores of Africa in droves to sell their skills in Europe, America and the Middle East. As a young doctor in a public hospital, one of the authors of this article saw many of the senior doctors leave for what later came to be known as “green pastures” in an exodus later dubbed “brain drain”. This meant that clients could not get services during an episode of illness or an emergency even if they managed to scrape some money together.

Consequently, as would be expected of any other population under such circumstances, the African people, particularly the expendables, fancifully called the “poorest quintiles” found alternatives which included the reinforcement of their beliefs in time-tested traditional medicine, self medication and in some cases, recourse to divine intervention during an episode of illness.

The consequences came in high disease burden, high infant and under-five mortalities as well as pregnancy related deaths. In other words, infanthood and young childhood became a very dangerous road for African newborns to navigate and pregnancy transformed into the dangerous Russian roulette for women. The statistics that rolled out of Africa became very alarming. It was evident that something had to be done.

The responses, when they came addressed other things but not the main problems. Firstly, big investments were made in building health facilities – health posts, health centers and hospitals in supposedly underserved communities. In some instances, these facilities were not equipped, and in many other instances where they were fully equipped, there were no staff to work in them. As health consultants, we saw many equipped health facilities in a state of abandon scattered across West Africa.

Secondly, the blame was shifted to the population. They did not know enough to protect themselves and their children and were ignorant of life threatening complications of diseases and pregnancies. Another round of big investments was made in informing and educating African people on individual self-care and protection of their children.

Thirdly, it was assumed that the lackluster performance of the largely demotivated available workforce was linked to lack of skills and knowledge. Large amounts of money were again spent on skill-upgrading trainings for health personnel. Considered a fashionable project output, many agencies fell over one another to train these personnel. It is not uncommon to see a nurse or a doctor who has been trained for five or more times on the same subject by different agencies using the same curriculum. The additional income from daily allowances (perdiems) paid by these agencies for the health staff made these unending trainings attractive.

If these strategies worked at all, the statistics did not show it. The achievement of any of the maternal and child health related targets of the Millennium Development Goals looked farther as 2015 approached.

It took the courage of an international agency sometime in 2005 to denounce the payment of user-fees as a major obstacle to any meaningful change in the preventable deaths of children and pregnant women. Many agencies have since conducted different studies on the impact of user-fees on health service uptake and have come to the same conclusion. It took close to twenty years to understand that many children and pregnant women from poor households were dying simply because the families could not afford to pay for health services.

The exemption of pregnant women and under-fives from payment of user fees soon became an important subject of advocacy and government lobby for different international agencies working in Africa. The “race” to meet the MDG maternal and child health targets at least halfway for most African countries has increased the tempo of pressure on African governments.

The response of African governments to this pressure has been dual. Firstly, it is a studied silence – a quiet wish that something else would soon catch the fancy of the agencies. African governments have come to learn that international agencies have a short attention span on any issue and will quickly shift their focus to wherever there are funds. And secondly, some, just because this new cliché won’t go away as soon as wished, have turned this into a political advantage. They simply declare free medical treatment for all children aged less than five years and payment-free consultation and delivery for all pregnant women. They want peace, so they jump the fence to placate and quieten overzealous lobbyists as well as score a political point at the home front. The financial and operational implications of their declaration elude these politicians.

Now that user-fee payment has been proved to be a public health hazard for children and pregnant women, and those that saw it as a “necessary evil” have been largely silenced, the challenge does not lie any longer in overbeating the drums of the benefits of the removal of user-fee payment but in proposing sustainable ways of its implementation in order to convince African governments that are sitting on the fence now and those who are intent on only making a political profit out of the issue that it is not only possible but also achievable.


Rob Yates said...

Many congratulations on your very well-researhed and accurate analysis of the health user fees debacle over the last 30 years. You are absolutely right, the debate has been won on this now, and the top priority must be to help governments replace user fee financing with more efficient and equitable financing mechanisms.

This means switching to prepaid mechanisms that pool financial resources and which facilitate the cross-subsidisation of the poor and needy. Evidence from around shows that only compulsory, publicly governed systems (tax financing and social insurance) can achieve this. Private voluntary mechansims (user fees and private insurance) will not enable a country to achieve universal coverage.

Rob Yates
On Twitter: @yates_rob

Yamba Kafando said...

Congratulations to Mr Abimbola. Very good analysis of the Bamako Initiative implementation of the IB during this last years. For my part I would say that Bamako Initiative has more or less succeeded in the availability of drugs (mostly generic) but failed in terms of equity. Direct payment excluded many people health systems in Africa.