Monday, May 06, 2013

A Dirge for Bamako Initiative By Abimbola Lagunju

 All African countries practice Bamako Initiative-inspired cost recovery system which is based on sales of services and medications to patients in health facilities. In other words, patients are supposed to pay for services at the point of healthcare delivery at all levels of the health system in order for the system to “recover” its “investments”. If you do not have money, you do not get services. It looks like a commercial transaction and indeed it is. Worse still, is that the so-called “cost recovery” factors in profit-making. Profits are made from these healthcare-for-sale transactions. Just like a supermarket!

Both the Central government and the health facilities make money from this arrangement. The Central Government through its Central Pharmacy Depot (different countries give different names to this central depot) sells drugs and hospital materials to health facilities at a profit. The health facilities are understandably under obligation to source their supplies from this central depot. The profits accrued from the sales of these supplies are then ploughed into the health financing system and they may represent between 30% and 40% of the national health budget. The rest of the budget is sourced from donors and from government funds. The source of government funds we assume is from taxes levied on the same people from whom the health system is making its profits.

At the level of the health facilities, the Central government provides the initial capital for the health facilities to “trade” with. Armed with this initial capital, the health facility purchases its supplies from the central depot and sells its drugs, materials and services to the population again at a profit. Profits accrued from the sales of services and drugs are partly used to pay health workers as a bonus and partly to pay contractual workers like guards or other support service providers who are not on government contract, but whose services the health facility adjudges to be necessary. Some of these profits may also be used for the procurement of administrative materials like patients’ cards and other stationery when the Ministry of Health fails to provide them.

The population is thus faced with the triple jeopardy of paying taxes, indirect purchase of supplies from the central depot and direct payment for services and drugs in health facilities in order to generate money for the government to finance the national health care system. The implication of this financial burden on the healthcare-seeking behavior of the largely poor population of West Africa has been discussed in a previous article (see: Bamako Initiative – Wrong medicine for the wrong ailment).

The healthcare financing system which is founded on multi-layered exploitation of the poor African population has become well-established over the years in many African countries and the mere thought of changing it for another system with a human face has become a nightmare scenario for many governments. They simply do not know how to face the challenges inherent in such a change, neither are they courageous to seek and propose alternative financing mechanisms.

Agreed that healthcare delivery system needs to be funded, and cash-strapped African governments need to find funds to finance it, however, the morality and the role of government as well as their social responsibility come under question when these States seek to extort funds from their impoverished population in the name of user-fee payment in order to fulfill its social obligation to safeguard their health.

What are African governments afraid of? The fear of African governments stems from the financial implication of discarding the health system financing structure they have been bullied and pressured to put in place. They do not know how and from where they will get funds to replace the 30 – 40% of their health budget which comes from user-fee payment. They have learnt to understand that declaration of intention by donors is not necessarily matched by concrete action. Many African governments have the experience of being been short-changed by many donors after and despite their lofty declarations. Thus, going with hat in hand to these donors to ask them to put up the potential health budget deficit, were African governments to scrap user-fee payment, is not a promising enterprise. The current and of unknown end financial crisis in donor Western countries has further made this prospect look like a pipe dream. If African governments want to do something about the death sentence that the user-fee has imposed on millions of under-fives and pregnant women, they have to look inwards.

But they are not looking inwards. Rather than study viable alternatives, some African governments against all possible logic, arbitrarily declare non-viable and inutile user-fee exemption in their states without back-up funds. The arrangement with the health facilities is on an IOU basis. The government promises to refund all expenses incurred from the treatment of under-fives and pregnant women to health facilities on presentation of documentary proof. Health facilities, under obligation to respect and implement this policy deliver services and give away drugs which they had paid for expecting the government to honour its promise. But the government does not honour its promise. And when it does, refunds are made many months later when the health facilities have long run out of drugs and materials. In some African states, this refund is done with some irrelevant in-kind payment which is not useful for the health facilities. In many others, the money is simply not refunded. Deprived of their capital and profits, these health facilities soon run out of drugs and materials. Armed with the declaration of the government, the gullible masses flock to these denuded health facilities to seek “free treatment” only to find that service delivery has moved from bad to worse.

How will African governments find their way out of this conundrum? Payment at the point of service delivery has been proved to alienate many who do not have the resources to pay. The immorality of excluding a large part of the population from the health system by governments whose primary social responsibility is to safeguard the health of all their citizens makes it mandatory and urgent to discard this system.

Post-payment approach in which the government promises to reimburse expenses incurred by health facilities for the treatment of under-fives and pregnant women is not only ineffective, but has also shown its potentials to further debilitate an already weak health system. Outsourcing the management of these reimbursements to an independent body is a possibility; however, politics, bureaucratic bottlenecks and corruption make this approach potentially unworkable.

A feasible but little-tested system of pre-payment may be the only choice left for African governments to explore. They need to look inwards to study which home-grown and fully government-funded pre-payment mechanism will be most suitable for each country. “One cap fits all” strategy in the style of Bamako Initiative and imports of half-baked social experiments should be avoided at all costs.

Abimbola Lagunju is a writer and author of several books.

Jean Pierre Papart is a writer, an author and a public health specialist

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