For the 25th anniversary of the Bamako Initiative and the Harare Declaration, we asked the historian and economist Jean-Benoît Falisse to conduct a series of interviews about community participation. In this first article, he introduces the topic.
Twenty-five years ago, the African Ministers of Health invited by UNICEF and WHO in Bamako, Mali, declared their willingness to improve access to essential medicines and health services. At the core of the Bamako Initiative (BI) is the belief that the participation of users in the management (and sometimes delivery) of health services can accelerate the achievement of primary health care, which is a concept that was formalized twelve years earlier at the Alma-Ata Conference (1978). The context of the Bamako Initiative is not unlike the one that prevails today in Southern Europe: states faced a serious economic setback (at the time the oil peak leading to the debt crisis) and fiscal austerity measures were imposed upon them by international institutions like the International Monetary Fund and the World Bank.
Twenty-five years after Bamako, "health for all" unfortunately remains at best a long-term ambition. Despite some local successes, community participation in health was not the magic bullet some had hoped for. This leads to a series of questions. To what extent did participatory initiatives in health bring changes? Are our expectations for community participation too high or is it, as an international civil servant told to me recently, that "we just did not really give a chance to community participation?”
In the coming months, I will share with you different contributions on the subject (1). I will try to understand the legacy of the BI and explain past, present and future strategies of community participation in health. As a preamble to the upcoming interviews, I will briefly introduce the BI, its historical context and some recent developments in the field. I have identified five key questions.
Question 1: What community participation?
At the heart of the BI is a threefold principle: (1) self-financing mechanisms at the peripheral and household levels, (2) encouragement of community mobilisation for health (community participation) and (3) improvement of drugs supply. Additional financing by communities has often been seen as the reason for increased community participation. The direct consequence of the community participation advocated by the BI has been the set-up of elected community committees in many African countries. These committees all have the ambition to make communities (co-)manage their health centres.
The idea follows 1970s’ and 1980s’ experiences and aims at providing a better interface between service providers (care staff) and patients. In the field, the role of (co-) administrator/manager granted to the community and its health committee is nevertheless conflated with another “weaker” and less empowering form of community participation: community health workers and other heirs of the "barefoot doctors" popularised by Maoist China policies. Often implemented by vertical programs, these health workers are an instrument to deliver services at the heart of communities, mostly on issues of disease control and prevention. In many national experiences, the distinction between the different forms of participation remains blurry. In particular, there is little distinction between community participation as a way to devolve services to community members and community participation as the community (co-)management of health centres. This confusion is in part reflecting two decades of debate on participation as either an end in itself or means for other purposes.
The 'content' of community participation is one of the questions we will explore in the forthcoming series of interviews. As I am writing this text from Bukavu in the Democratic Republic of Congo, where members of health committees are also community health workers (they are sensitisation and liaison officers as well as co-managers), I believe that the issue is relevant well beyond academic circles or ideological divide.
Question 2: What integration in the political context?
Before the BI, it was rather the non-aligned and socialist sympathisers’ countries that experimented community participation (Tanzania, Kenya, India, etc.). The BI must be seen as a follow-up of the Alma-Ata Declaration, which remains a surprising commitment of the countries of the world -including in the West- to a political philosophy marked by experiences of Chinese decentralised socialism (village communities managing their health) (2). However, the BI is also the child of the Washington Consensus, new public management, “good” governance and market paradigms. In fact, the BI ideas seem to have been endorsed by a wide spectrum of international development practitioners: from the legatees of the "1968 movement" to the supporters of the Reagan / Thatcher 1980s neo-liberal come-back, from grassroots NGOs to the World Bank.
In the years that followed the BI, the debate about the nature of community participation (empowerment or instrument) has certainly occurred in some (academic) circles but on the field, roughly the same type of "health committees" have been implemented across the African continent. Surprisingly, the political dimension of citizen participation in the management of basic social services (such as health care) has been little discussed (this is the issue of “power”). Since 1987, much water has flowed under the bridge: decentralisation but also democracy have spread throughout Africa. In our series of interviews, we will consider how community participation – sometimes presented as a technocratic proposal – occurs in the context of social, political and economic mobilisation at the local level. What part of the population is included in strategies of community participation? What are the links between community participation and local and national politics?
Question 3: New health policies, new forms of participation?
Although community participation has not exactly met all expectations of the participants of the conference in Bamako, it has also evolved in contact with new health policies. Some of these policies, pretty much as the BI was in its time, have generated high hopes for improving health and access to care.
For instance, performance-based financing strategies are questioning the role of the community as a stakeholder. Can it be contracted for delivering services to the population? Can it be used as a tool to perform verification tasks in the system? Should rather community be strengthened in its role as a co-manager, as proposed by the BI? Should it become a watchdog that ensures that performances and results meet the needs of the population? How to ensure that the voice of the people continues to be transmitted and heard when financial incentives drive the system?
Free health care on a large scale also poses new challenges. Although the BI was not limited to cost recovery, it has often been read as such. In the BI model, the money collected from households paying for care is used to develop services and promote access (sometimes via a waiver scheme) to essential treatments, including for vulnerable groups identified by the health committees. With the removal of user fees, the financial interest community members have in the health centre management disappears. Could it be that the motivation of the population to participate is affected?
Free care and performance-based financing are two of the most popular health policies currently being developed in Africa and this series of interviews will assess their implications for community participation in health.
Question 4: Accountability, a paradigm shift?
The 25 years that have passed since the BI also correspond to changes in the language of international health (nowadays people talk about “global” health). The mainstream rhetoric has put "community participation" a little bit aside as the popularity of terms such as "accountability" and "transparency" has been rising. These concepts combine readily with "community" or "social", and the question now becomes whether the spirit of community participation promoted by the BI remains within the "new" concepts of accountability, governance and transparency. A whole new generation of policies and strategies of "social accountability" in health but also in other basic social services are appearing (balanced score cards, social audit, etc.). Do these strategies imply the same kind of community involvement that the one advocated by the BI? Is “community accountability” an enhanced version of "community participation" or rather its bleak ersatz?
Question 5: What about the research?
Alongside these developments in health policies and strategies, research about community participation has also evolved in the last 25 years. In the last few years, new methodologies have developed. They propose a more quantitative approach, sometimes mixed with qualitative insights and contrast with ethnographic and sociological approaches that have been usually used for the study of community participation (pre- and post-Bamako). “What can we learn from these new research methods?” and “what is the state of research on the mechanisms of community participation?” will constitute a final theme of our series.
Bearing all these issues in mind, we will meet researchers and practitioners of community participation. Listening to their reactions and comments, we hope to better understand the heritage of the Bamako Initiative and the future of community participation in health.
(1) This is the topic of my DPhil at the University of Oxford and the central idea of different interventions Cordaid is experimenting in the African Great Lakes with Cordaid, of which I hope to document the impact soon.
(2) In retrospect, we can assume that high-income countries were taking little risk when signing a text where low and middle-income countries entrust local communities to manage and finance their health care.