Gyuri Fritsche

On 26 April Robert Soeters, overwhelmed and blushingly accepted a Royal decoration from the hands of Mayor Jozias van Aartsen in an annual public ceremony colloquially called the lintjes regen (the decorations rainfall). A close group of friends, colleagues and members of family had organized and requested the nomination without Robert’s knowledge, and had lured him from Africa (where he is mostly found) to The Hague (where he sometimes resides) for a work meeting after which he was ushered in front of the decorating official. Robert has worked his entire professional career with passion on refining a sophisticated public health intervention that has gained currency as ‘Performance-based financing’. Please join us in calling Robert from now on ‘Sir Robert’!

Ce 26 avril, submergé par l'émotion et rougissant, Robert Soeters a accepté une décoration royale des mains du Maire Jozias van Aaartsen lors d'une cérémonie publique annuelle familièrement appelé le lintjes regen (pluie des décorations). Un groupe d'amis proches, collègues et membres de la famille avait organisé et proposé sa nomination, à son insu. Ils ont dû le tirer d'Afrique (où il se trouve principalement) pour le faire venir à La Haye (où il réside parfois) pour une réunion de travail, après quoi il a été conduit devant l'officiel en charge des décorations. Robert a travaillé toute sa carrière professionnelle avec passion à peaufiner une intervention sophistiquée de santé publique qui est connue aujourd'hui comme le « financement basé sur la performance ». S'il vous plaît joignez vous à nous pour appeler Robert à partir de maintenant 'Sir Robert'!

La deuxième partie de notre entretien avec le Dr Agostino Paganini nous amène à traiter de l'évolution de l'Initiative de Bamako dans le temps et de sa dimension politique. Après son travail en tant que directeur de l'Initiative de Bamako de l'UNICEF à New-York, le Dr Paganini a continué à travailler avec l'UNICEF en tant que chef d'équipe pour la santé dans les situations d'urgence et en tant que directeur pays en Somalie. Il a également travaillé comme consultant senior pour la Banque Mondiale et conseille le directeur de CUAMM (Médecins avec l'Afrique). (Vous pouvez accéder à la première partie de l'interview ici)

Avec le recul, certaines personnes disent que le programme de l'Initiative de Bamako a rarement été correctement mis en œuvre. Dans un post sur ce blog et dans un article, Valery Ridde dit même que nous devrions peut-être abolir l'Initiative de Bamako. Comment voyez-vous la mise en œuvre des principes de Bamako jusqu'à maintenant?

Je pense que cette initiative est morte il y a longtemps. Je pense que certains de ces principes sont toujours incroyablement valables et que certains des problèmes auxquels elle tentait de répondre existent toujours. Le problème de la responsabilité publique et de la participation des populations dans la gestion de leur système de santé aurait dû être mieux pris en compte avec plus de démocratie, mais il est toujours laissé sans intérêt dans de nombreux pays africains. Le problème des dépenses « out-of-pocket » sans aucune règle est également toujours extrêmement valable. On peut appeler cela l'Initiative de Bamako ou on peut l’appeler comme on veut, cela n'a pas vraiment d'importance: quelques-uns des problèmes auxquels l'Initiative de Bamako tentait de répondre sont toujours là et certaines des expériences et des principes (dont certains ont été appliqués et certains ont été mal appliqués) sont toujours d'actualité. Mais l'initiative, non, je ne pense pas qu'il existe chose comme l’initiative de Bamako en vie pour le moment. Tout du moins, je n'ai rien vu.

Seriez-vous d'accord avec Susan Rifkin, qui déclare que l'Initiative de Bamako a élargi les horizons de la participation de la communauté? Est-ce que l’utilisation du terme redevabilité communautaire au lieu de participation change quelque chose ?

Soyons clairs, la redevabilité communautaire cela veut dire la redevabilité envers la communauté. La différence avec cette notion c’est que les communautés deviennent propriétaires (« shareholders »). Avant ils payaient sous la table, maintenant ils paient et ils peuvent demander "qu'avez-vous fait de l'argent?", "pourquoi n'avez-vous pas fait ceci ou cela?". C'est la différence entre un processus participatif vague et une représentation et une participation dans la gestion de l'unité de santé. Et c'est quelque chose sur lequel nous devons encore travailler. Les gens n'ont pas voix au chapitre (« voice ») et aucune porte de sortie (« exit ») dans les pays à faible revenu, sauf bien sûr d’aller dans le secteur privé, mais ce n'est pas une option pour les pauvres.

Dans sa récente interview sur ce blog, Sassy Molyneux insiste sur le fait qu'il faut « examiner attentivement la rémunération et les autres formes d'incitations pour les représentants de la communauté, les défis de l'asymétrie entre le personnel de santé et les représentants de la communauté en matière de ressources et de pouvoir, et l'importance de bâtir des relations de confiance ». Pour moi, cela ressemble un peu à considérer la « politique locale » de santé. Il m'a toujours semblé que peu d'attention était portée à la dimension politique dans l’Initiative de Bamako. Nous sommes pourtant dans une sorte de processus politique, non?

Oui, c’est politique. Et ne pas comprendre que c'est politique est la plus grosse erreur que vous pourriez faire. Je pense que dans la communauté de la santé publique, nous sommes parfois très naïfs. Nous pensons à la supervision et à la formation comme les clefs de tout, mais la santé c’est politique. C'est pourquoi les États-Unis ont leur système de santé, et c'est pourquoi les Scandinaves ont un système de santé différent. La science est la science, mais la façon dont la science est disponible ainsi que la qualité et l'équité de l'accès aux soins sont des questions politiques. Nous devons accepter que le chemin pour obtenir des soins de santé de haute qualité et équitables est difficile et que nous ne sommes pas encore là. Il y a encore une énorme asymétrie entre le personnel de santé et la population, et c'est un signe que la démocratie n'est pas encore là. Nous devons commencer à partir de ce problème. Ce que j'ai vu avec l'Initiative de Bamako est une question profondément politique, et non strictement technique. Mais bien sûr, les gens utilisent des choses et des déclarations de différentes manières et ils ont utilisé cette initiative en fonction de leurs propres intérêts et points de vue.

Vingt-cinq ans ont passé. Vous avez une grande expérience des soins de santé primaires dans les pays à faible revenu. Quelles seront les clés pour les soins de santé primaires au cours des 25 prochaines années?

Ce que je vois venir est plus de privatisation et plus d'urbanisation. Les gens semblent trouver dans les zones urbaines et même dans les bidonvilles des opportunités qu'ils n'ont pas dans leurs zones rurales. Certains pays sont de plus en plus avancés dans l'établissement de l'assurance-maladie –ce qui est une excellente chose, je pense. A la fin de mon travail sur l'Initiative de Bamako, nous étions focalisés sur deux choses (il y avait deux équipes). L'une était le monitoring communautaire, car l’information c’est le pouvoir. L'autre était l'assurance locale. L'assurance maladie est un enjeu majeur, mais elle est difficile à établir. Dans de nombreux cas les programmes commencent à l'échelon national, et pourtant, en Europe ce sont des mécanismes de solidarité locaux qui ont été les assurances initiales.

Nous devons travailler sur la responsabilité/redevabilité publique et l’équité. Ce sont les deux domaines clés. Allons-nous dans cette direction? Je ne suis pas sûr. Je pense que dans certains pays, nous le sommes, mais dans la majorité des autres pays, le secteur privé est de plus en plus important car les gens ont plus de ressources et le secteur public reste sous-financé. Qui plus est, ce secteur public est très inefficace à moins qu'il y ait une forme de redevabilité envers le public. C'est le bilan mitigé que j'ai. D'un côté, il y a des pays qui progressent bien ; prenez par exemple l'expérience du Rwanda avec les mutuelles de santé et la nouvelle politique de rémunération du personnel. Mais de l'autre côté, il y a beaucoup d'autres pays, qui, je pense, ne vont pas dans le même sens.

Est-ce qu’il y a une question que je ne vous ai pas posée et que vous auriez souhaité que je vous pose ? Ou bien une conclusion que vous souhaiteriez faire?

Pas vraiment, pour moi c'était une expérience fascinante. J'ai réalisé que c'était aussi un débat passionnant. Certaines de ces questions sont, comme je l'ai dit, très politiques et certaines sont extrêmement pertinentes aujourd'hui. Nous devons aborder la relation entre le patient, le client et le fournisseur de services. Le débat actuel sur le financement basé sur la performance, qui lie financement non aux médicaments, mais aux résultats, est également très intéressant. Bien sûr, cela ne résoudra pas tous les problèmes. Je pense que nous devrions être en mesure de voir quelles ont été les bonnes expériences dans le passé et aller de l'avant, en ajoutant de nouvelles expériences. La responsabilité publique de base et le rôle des populations sont extrêmement importants, la bonne gouvernance des centres de santé est très importante, mais le financement basé sur les résultats est également très prometteur si nous le combinons avec d'autres choses que nous avons apprises. Nous ne devons pas passer de mode en la mode, mais de prendre en compte le passé, comprendre ce que nous avons appris et le développer.

The second part of our interview with Dr. Agostino Paganini brings us to the evolution of the Bamako Initiative over time and its political feature. Agostino Paganini has an extensive experience of primary health care and emergency health care in Africa, an area in which he has been active for over forty years now.  He was the manager of the Bamako Initiative (BI) Support Unit at the UNICEF HQ. The unit worked closely with African countries that had shown interest in the principles of the BI. In the 1990s’ and 2000s’, he continued to work with UNICEF as a Team Leader for Health in Emergencies and as a country director in Somalia. He has also done senior consultancy work with the World Bank and advises the director of CUAMM (Doctors With Africa).

In retrospect, some people say the Bamako agenda has rarely been properly implemented. In a post on this blog and in an article, Valery Ridde says we me be better abolishing the Bamako Initiative (it is of course a provocation). How do you view the implementation of the Bamako principles until now?

Absolutely. I think this initiative died a long time ago. I think some of the principles are still incredibly valid and some of the problems it was trying to address also still exist. The problem of public accountability and people participation in the management of their health system should be have been better addressed with more democracy but still, it is left unattended in many African countries. The problem of out-of-pocket expenditures with no rules is also still extremely valid. We can call it Bamako Initiative or we can call it the way we want, it does not really matter: some of the problems which the Bamako was trying to address are still there and some of the experiences and principles (some have been applied and some have been badly applied) are still very relevant. But as an initiative, no, I do not think there is such thing as a Bamako Initiative alive at the moment. At least I have not seen anything. 

Would you agree with Susan Rifkin who says that the Bamako Initiative has widened the horizons of community participation? Do you see the current shift from community participation to community accountability as another widening?

Let's be clear, community accountability is accountability towards the community. The difference now is that communities become shareholders. Before they were paying under the table, now they pay and they can ask, what have you done with the money, why have you not done this or that? This is the difference between a vague participatory process and being represented and part of the management of the health unit. And this is something we still need to work on. People have no voice and no exit in low-income countries, except to go to the private sector, but this is not for the poor.

In her recent interview on this blog, Sassy Molyneux insists that we must “carefully consider remuneration and other forms of incentives for community representatives, the challenges of asymmetries between health staff and community representatives in resources and power, and the importance of building trustful relationships”. To me, this sounds a bit like considering the local politics of health. It always struck me how little attention seems to be paid to politics in the BI. We are in a sort of political process, right?

It is political. And not understanding that it is political is the biggest mistake you could do. I think that within the public health community we are sometimes very naïve. We think about supervision and training as the keys to everything but health is political. This is why the US has its health system and this is why Scandinavians have a different health system. Science is science but how science is available as well as the quality of and equity in access to care are political issues. We have to accept it is a though road to get to high quality equitable health care and we are not there yet. There still is a huge asymmetry between the health staff and the people and it is a sign that democracy is not there yet. We need to start from this problem. What I have seen with the Bamako Initiative is a deeply political, not a strictly technical, issue. But of course, people use things and declarations in different ways and they have used this initiative according to their own interests and point of view.

Twenty five years have passed. You have an extensive experience of primary health care in low income countries. According to you, what will be the keys for primary health care in the next 25 years?

What I see coming is more privatisation and more urbanisation. People seem to find in urban areas and even in slums opportunities they do not have in their rural areas. Some countries are growing and establishing health insurance which is an excellent thing I think. At the end of my time working on the Bamako Initiative, we were working on two things (there were two teams). One was community-based monitoring, because data are power. The other was local insurance. Health insurance is a key issue but it is difficult to establish. In many case they start at the national level; yet, in Europe local solidarity mechanisms were the initial insurances.

We need to work on public accountability and equity. These are the two key areas. Are we going in this direction? I am not sure. I think in some countries we are, but in a majority of other countries the private sector is growing as people have more resources and the public sector remains under-financed. What is more, this public sector is very inefficient unless there is public accountability. This is the mixed picture I have. On one side, they are countries progressing, doing very going things. Take for instance the experience of Rwanda with community-based health insurance (French: mutuelles de santé) and new staff remuneration policy. But on the other side, there are many others I think are not going in the same direction.

Any questions I have not asked and you would have liked me to ask or any conclusion you would like to make?

Not really, for me, as I said, it was a fascinating experience. I realised it was also a fascinating debate. Some of the issues are, as I said, very political and some are extremely relevant now. We have to address the relation between the patient, the client and the provider. The current debate of performance-based financing, which is linking financing not to the drugs but to the results, is also extremely interesting. Of course, it will not solve all the problems. I think we should be able to see what the good experiences were in the past and move on, adding on new experiences and new things. Basic public accountability and the role of people is extremely important, good governance of health facilities is very important but result-based financing of health facilities is also very promising if we combine it with other things we have learned. We should not move from fashion to fashion but take the past into account, understand what we have learned and build on it.

Jean-Benoît Falisse

Pour l’interview suivante de notre série sur la participation communautaire et l'Initiative de Bamako, nous avons rencontré le docteur Agostino Paganini. Agostino Paganini a une vaste expérience des soins de santé primaires et d'urgence en Afrique, un domaine dans lequel il a été actif pendant plus de quarante ans. Il était le directeur de l'unité de soutien à l’initiative de Bamako au siège de l'UNICEF. L'unité travaillait en étroite collaboration avec les pays africains qui avaient manifesté leur intérêt pour les principes de l’Initiative de Bamako. Dans la première partie de l'interview que nous publions aujourd'hui, il partage son analyse de la mise en place de l'Initiative de Bamako. La semaine prochaine, nous découvrirons son analyse de l'évolution des principes de l'Initiative de Bamako au fil du temps.

Jean-Benoît Falisse: Si je ne me trompe pas, vous avez participé à la conférence de Bamako. C'était la 38e réunion régionale africaine de l'OMS, mais l'UNICEF y a également pris part. Que faisiez-vous à ce moment? D’où l'Initiative de Bamako venait-elle?

Agostino Paganini: A cette époque, je travaillais sur un programme conjoint UNICEF-OMS de soutien nutritionnel. J'étais basé à New York et techniquement je travaillais pour l'OMS. Je n'étais pas là à Bamako, mais mon expérience de l'événement est encore vivace. Je me souviens très bien des implications organisationnelles et de toutes les retombées et les aboutissants de cette initiative de M. Grant. Bien sûr, tout ce que je vais dire dans cette conversation pourrait être biaisé, c’est ma propre expérience telle que j'ai revue et comprise au fil des années. A cette époque, le Dr Halfdan Mahler était le Directeur général de l'OMS, et M. Jim Grant était le Directeur exécutif de l'UNICEF. Tous deux étaient des dirigeants extrêmement charismatiques et puissants et ils étaient deux figures majeures du débat en santé publique et sur le développement de la santé. Mahler mettait l’accent sur les soins de santé primaires, avec une vision globale et une sensibilité aux implications politiques. Grant était beaucoup plus pragmatique, il croyait en une vision de type « guerre froide », où il y avait peu de chances de progrès importants, et il croyait donc en des étapes successives qui amèneraient l'éducation à la santé dans l'arène politique. Après la déclaration de Harare [sur le renforcement du système de district de santé fondé sur les soins de santé primaires], Grant est venu avec Bamako. Pas nécessairement, contrairement à ce que certains ont cru percevoir, comme une déclaration antagoniste à Harare, mais peut-être plus comme une déclaration plus progressive, moins « visionnaire ». Bien sûr, pour lui, c'était aussi un moyen de faire du plaidoyer pour l'Afrique parce qu'il voulait plus de ressources pour l'organisation de la santé et la survie des enfants en Afrique - et il a vu la déclaration comme un moyen de les avoir. Fondamentalement, la relation entre les déclarations de Bamako et Harare pourrait être considérée dans le contexte d'un débat intellectuel entre ces deux géants des questions de développement.

Dans le contexte de ce débat intellectuel, qui faisait pression pour l'Initiative de Bamako? Quels ont été les principaux points de consensus et de divergence entre les pays et / ou organisations?

Aux côtés des ministres africains, l'UNICEF a encouragé et fait pression pour ce genre de déclaration - pour laquelle l'OMS n'était pas particulièrement enthousiaste. En fait, même certaines parties de l'UNICEF n'étaient pas très heureuse à ce sujet. Au niveau politique, ce qui était évidemment le plus difficile à accepter c'était la question des frais d'utilisation et du partage des coûts. L'UNICEF et M. Grant, sur base de ce qui se passait au Bénin et dans de nombreux pays africains, s'est rendu compte que le payeur réel en matière de santé n'était pas le gouvernement, pas plus que le bailleur, c’était le foyer, le ménage. La majorité des dépenses étaient payées directement de la poche des foyers. Il s'agissait donc de «co-financement». Comme certaines personnes identifiaient cette idée d'avoir les gens co-financer leurs services de santé avec la vision de la Banque Mondiale sur les frais d'utilisation, le débat est devenu très idéologique. Dans la proposition de l'Initiative de Bamako, il était suggéré que les gens paieraient quelque chose de leur poche. Si les bailleurs aidaient à améliorer les services en termes d'infrastructure, de disponibilité des médicaments, de formation et de supervision du personnel et de mécanismes de suivi, on aurait tort de considérer que les gens ne doivent pas contribuer du tout au coût de la prestation de services (même si c’est en payant moins que le coût réel). Cet argent resterait avec les gens qui avaient payé, au niveau du centre de santé, et il serait contrôlé par la communauté. C'était l'hypothèse. La réaction de l'autre côté a été de crier à la privatisation et d’appeler cela un moyen de faire payer les gens pour la santé, alors que la santé est un droit humain fondamental qui ne peut être vendu.

Une partie de l'Initiative de Bamako porte sur  la participation communautaire. Dans l'entrevue avec Susan Rifkin, elle explique que son intérêt pour la participation de la communauté a commencé avec l'expérience des médecins aux pieds nus en Chine. Y a-t-il quelque chose de semblable en Afrique? Quelque chose qui a convaincu les gens à Bamako?

Dans l'unité que je gérais à New York, tout le monde était absolument convaincu que le plus grand changement politique qu’a apporté l’initiative de Bamako n'était pas d’abord lié à l'argent mais à l'effort pour renforcer les communautés dans leur contrôle des centres de santé et de leur personnel. Nous avions l'impression que le personnel de santé avait alors en quelque sorte privatisé le système de santé. Le système de santé ne fonctionnait plus, il s'agissait d'un secteur privé non-réglementé où vous aviez à payer pour tout, sans aucun contrôle sur la qualité ou sur l'utilisation de l'argent. Pour nous, l'Initiative de Bamako était un moyen de renforcer la capacité des gens à faire partie et prendre part à la gestion du centre de santé. Il ne s'agissait pas de la gestion technique du centre de santé, mais bien des aspects de  «gouvernance». Est-ce que cela a été un succès? Dans certains endroits, comme au Mali au début, c'était assez bon. Pourtant, j'ai eu l'impression que, après un certain temps, l'Initiative de Bamako a été interprétée/considérée par certains des ministères de la Santé comme une excuse pour faire payer tout ce qu'ils voulaient sans aucun contrôle par la communauté sur l'argent.

Au niveau communautaire, qu’est ce qui était en place au moment de la déclaration de l'Initiative de Bamako?

Dans certains pays, il y avait des comités de santé, mais ces comités de santé n’avaient jamais de contrôle sur aucune ressource. Dans ces pays, on pourrait partir de ces comités. Cependant, dans d'autres pays comme la Guinée après Sékou Touré, il n'y avait rien. Le système de santé avait été détruit et avec le ministère de la Santé de la Guinée, des comités de gestion ont été mis en place. Ce fut le début d’un mouvement qui allait donner de la substance à la participation communautaire à travers le co-financement et la cogestion des centres de santé. Tel était le langage que nous voulions utiliser, non pas « recouvrement des coûts », mais « cogestion communautaire et co-financement ». Cela a été mis en œuvre dans différents pays et sous des étiquettes différentes. Il s'agit d'un processus fastidieux qui nécessite beaucoup d’appui au niveau communautaire.

L'Initiative de Bamako pourrait être décrite comme ayant trois piliers: (1) participation communautaire, (2) mécanismes d'autofinancement et (3) un approvisionnement régulier en médicaments. Vous avez déjà abordé les deux premières questions, pourriez-vous dire un mot sur l'approvisionnement régulier en médicaments?

L'expérience sur le terrain est que les centres de santé n'étaient pas utilisés et leur utilisation était incroyablement basse pour deux raisons: (1) une était lié à l'infrastructure et au comportement du personnel qui étaient perçus comme 'pourris' et donc les centres de santé déclinaient et l'autre (2), c'est qu'il n'y avait pas de médicaments. Les médicaments sont perçus par les utilisateurs comme un élément clé dans le processus thérapeutique, et c'est fondamentalement vrai où que vous soyez. Les gens dépensaient leur argent sur le marché non réglementé ou n'importe où ailleurs. Il était évident que les médicaments devaient être disponibles dans le centre de santé. Le centre de santé devait devenir le lieu non seulement pour les soins préventifs, mais aussi pour les services curatifs. Il ne faut pas oublier que la principale préoccupation de l'UNICEF à cette époque ce n'était pas des soins curatifs, c'était principalement la vaccination et la survie des enfants (qui sont pour la plupart liés à des soins préventifs). Toutefois, amener les personnes au centre de santé en raison de la disponibilité des médicaments pour leurs besoins curatifs était une façon de travailler sur le côté préventif.

Je prends un exemple: la survie des enfants et le paludisme sont deux problèmes très évidents de l'Afrique qui n'étaient pas très bien pris en charge. Il y avait des programmes verticaux avec des antibiotiques et des médicaments antipaludiques, mais ils n'étaient pas suffisants. Avoir un centre de santé fonctionnel était donc vu par nous comme un moyen de tendre vers une vision beaucoup plus globale des soins de santé primaires. C'était un processus graduel par lequel les staffs de santé étaient formés et les centres de santé améliorés grâce à des investissements des bailleurs de fonds et du gouvernement. Les frais de fonctionnement qui n’étaient pas couverts par le gouvernement étaient cofinancés par la communauté. La clé était d'avoir un comité qui supervise la gestion de l'argent afin qu'il y ait de la redevabilité envers le public. La participation communautaire était considérée comme un moyen de faire en sorte que le personnel médical et administratif rende compte à la population. Ce système de monitoring était fondamental car il permettrait aussi au comité de direction et au personnel d'avoir une vue sur la couverture et la vaccination, le nombre de visites, le nombre de femmes qui ont accouché, etc. De cette façon, ils pouvaient se fixer des objectifs, discuter entre membres du comité et personnel de santé des goulots d'étranglement dans le système et, en fin de compte, améliorer la durabilité, l'accès et l'utilisation correcte des services.

(à suivre)

The next interview of our series on community participation and the Bamako Initiative is with Dr. Agostino Paganini. Agostino Paganini has an extensive experience of primary health care and emergency health care in Africa, an area in which he has been active for over forty years.  He was the manager of the Bamako Initiative Support Unit at the UNICEF HQ. The unit worked closely with African countries that had shown interest in the principles of the Bamako Initiative. In the first part of the interview we publish today, he shares his analysis of the set-up of the Bamako Initiative. Next week, we will discover his analysis of the evolution of the Bamako Initiative principles over time.

Jean-Benoît Falisse: If I am correct, you took part to the Bamako conference. It was the 38th African Regional Meeting of WHO but UNICEF also became involved. What were you doing at that time? Where was the Bamako Initiative coming from?

Agostino Paganini: At that point of time, I was working on a joint UNICEF-WHO nutrition support programme. I was based in New York and technically working for WHO. I was not there in Bamako but my experience of the event is still vivid. I remember quite well the organisational implications and all the fall-outs of this initiative of Mr. Grant. Of course, everything in this conversation could be biased, it is my own experience that I have revisited and understood over the years. At that time, Dr. Halfdan Mahler was the Director General of WHO and Mr. Jim Grant was the Executive Director of UNICEF. Both were extremely charismatic and powerful leaders and they were two major figures in the public health and health development debate. Mahler had a focus on primary health care issues with a global vision and sensitivity to political implications. Grant was much more pragmatic, he believed in that sort of 'cold war vision' where there were little chances for big progresses and therefore he believed in incremental steps, bringing up health in the political arena. After the Harare declaration [on strengthening the district health systems based on Primary health care], Grant came up with Bamako. Not necessarily, as perceived by some, as a declaration antagonistic to Harare's but maybe as a more incremental, less 'visionary', declaration. Of course, for him it was also a way to call for Africa because he wanted more resources for health organisation and child survival in Africa and he saw the declaration as a way to have them. Basically, the relation between the Bamako and Harare declarations could be seen in the context of an intellectual debate between these two giants of developmental issues.

In the context of this intellectual debate, who was pushing for the Bamako Initiative? What were the main points of consensus and divergence between the countries and/or organisations?

Alongside with the African Ministers, UNICEF promoted and lobbied for this kind of declaration – for which WHO was not especially keen. Actually, even some parts of UNICEF were not happy about this. At the policy level, what was obviously the most difficult to accept was the issue of user fees and cost-sharing. UNICEF and Mr. Grant, on the basis of what was happening in Benin and many African countries, realised that the real payer in health was not the government any more, it was not even the donor any more, it was the household. The majority of expenditures were paid out-of-pocket. The issue was therefore 'co-financing'. Yet, some people identified this idea of having people co-financing their health services with the World Bank vision on user fees and the debate became very ideological. In the proposition for the Bamako Initiative, it was suggested that people would pay something out-of-pocket. If donors were helping making the service better in terms of infrastructure, drugs availability, training and supervision of staff and monitoring mechanisms, it would be wrong that people do not contribute to the cost of delivering services (although paying less than the actual cost). However, that money would stay with people who paid, at the health centre level, and it would be controlled by the community. That was the hypothesis. The reaction from the other side was to call this opening the door to privatisation and a way to have people pay for health when health is a basic human right which cannot be sold.

Part of the Bamako Initiative is about community participation. In the interview with Susan Rifkin, she says what sparkled her interest in community participation was the experience of barefoot doctors in China. Was there anything similar in Africa? Something that convinced people in Bamako?

In the unit I was managing in New York, everybody was absolutely convinced that the biggest political change that Bamako initiative was bringing was not the money but the effort to empower the community in controlling their health centres and staff. We had the impression that the health staff had basically privatised the health system. The health system was not functioning any more. It was an unregulated private sector in which you would have to pay for everything without any control on the quality or the use of the money. For us, the Bamako Initiative was a way to strengthen the capacity of people to be part of and take part in the management of the health centre. It was not about the technical management of the health centre but about the ‘governance’ aspect of it. Was it successful? Well, in certain places like in Mali in the beginning it was quite good. Yet, I had the impression that after a while the Bamako Initiative was interpreted/considered by some of the Ministries of Health and staffs as an excuse to charge whatever they wanted with no control by the community on the money.

Community-wise, what was in place at the time of the Bamako Initiative declaration?

In some countries, there were health committees but these health committees never controlled any resource. In these countries, we could start from these committees. However, in other countries such as Guinea after Sékou Touré, there was nothing. The health system had been destroyed and with the Ministry of Health of Guinea, managing committees were set up. It was the beginning of giving substance to community participation through the co-financing and co-management of the health centres. That was the language we wanted to use; not ‘cost recovery’ but ‘community co-management and co-financing’. It was implemented in different countries and under different labels. This is a labour intensive process that requires a lot of assistance at the community-level.

The Bamako Initiative could be described as having three pillars: (1) community participation, (2) self-financing mechanisms and (3) regular supply of drugs. You already touched the first two issues, could you say a word about the regular supply of drugs?

The experience on the ground was that health centres were not used and their utilisation was incredibly low for two reasons: (1) one was linked with the infrastructure and the behaviour of the staff which were perceived as rotten and so the centres were going down and the other (2) was that there were no drugs. Medicine is perceived by the users as the key element in the therapeutic process, and this is basically true wherever you are. People were spending their money on the market, buying drugs in the unregulated market or anywhere else. It was obvious that medicine had to be available in the health centre. The health centre had to become the place not only for preventive care but also for curative services. Do not forget that the main preoccupation of UNICEF at that time was not curative care; it was mainly immunisation and child survival (which are mostly linked to preventive care). However, having people coming to the health centre because of the availability of medicine for their curative needs was an important key for preventive purposes.

I take an example: child survival and malaria were two of Africa’s very obvious problems which were not very well addressed. There were vertical programmes with antibiotics and antimalarial drugs but they were not sufficient. Having a functional health centre was seen by us as a way to move towards a much more comprehensive vision of primary health care. It was a gradual process through which health staffs were trained and health centres improved thanks to investments from donors and the government. The running costs that were not covered by the government were co-financed by the community. The key was to have a committee which would oversee the management of the money so that there was public accountability. Community participation was seen as a way to obtain accountability from the medical and managerial staff. Monitoring was also a pillar in the system because it would allow the managing committee and the staff to have a view on coverage and immunisation, number of visits, number of women who were delivering babies, etc. This way they could set objectives, discuss between the members of the committee and the health staff, find bottlenecks in the system, and eventually improve the durability, access and correct utilisation of health care.

Emmanuel Ngabire (School of Public Health, Kigali and co-facilitator of the PBF CoP) interviews Juliet Nabyonga Orem (WHO, Uganda office and lecturer at Makerere University School of Public Health) on a recent paper she co-authored with Joses Kirigia (Coordinator at WHO AFRO) and Luis Sambo (Director of WHO AFRO). The paper assesses 10 years of health care financing in African countries through national health account data.

Juliet, what were the objectives of this research?

The way the health system is financed has a bearing on the extent to which it can improve access to good quality health services and, protect households against financial hardship.  Health financing plays a central role in achieving MDG targets and Universal Health Coverage (UHC).  We note that several countries in the WHO African Region are lagging behind on meeting MDG targets; we undertook this research to understand the health financing changes that have occurred in countries, taking into account the main sources of funding over a 10 year period (2000 to 2009).  Several countries in the Region are concerned with the low level of funding and high out-of-pocket payment (OOP), several are in the process or starting to elaborate health financing strategies while others are discussing/designing/implementing health financing reforms.  This trend analysis can guide the debate on appropriate health financing strategies but also guide design of health financing reforms.

What are your main findings?

We noted varied levels of expenditure on health with some countries increasing investments while others reduced over the 10 year period.  The number of countries achieving the Commission for Macroeconomics and Health recommendation of spending at least US$34 per person per year increased from 11 to 29 while number of countries achieving the International Taskforce on Innovative Financing recommendation of spending at least US$44 per person per year increased from 11 to 24.

Governments’ investment in health has increased in majority of countries over the 10 years period as evidenced by government spending on health as a percentage of total health expenditure increasing in 31 countries (out of 45 countries).  We however noted that this decreased in 13 countries.  Although the significance of private sources as a percentage of total health expenditure reduced, as evidenced by number of countries where private spending was 50% and above of total health expenditure decreasing from 29 (64%) to 23 (51%);  OOP expenditure is still high and majority of countries are far from ensuring financial risk protection.  Increase in prepayment through insurance was meager as evidenced by countries partially financing health through social security increasing from 19 to 21 and number of countries with private prepaid plans increasing from 29 to 31.

The results of your research revealed significant variation across countries in terms of government expenditure on health as a percentage of total government expenditure, and in terms of changes over the 10 years. According to you, what are major factors that made some government to increase their funding on and others decrease it?

Government funding plays a key role in financing health services given that it is flexible and more predictable than, for example, donor funding. It is a demonstration of government’s commitment to invest in health development of its citizens. In this research we indeed noted significant variations with some countries increasing their contribution to health as a percentage of total government expenditure while others reduced over the 10 year period.

There are several factors that made some governments increase their funding but we look at a few for some countries.

The commitment made by Heads of state in Abuja in 2001 could partly explain the increases in some of the countries.  This commitment has been reiterated in several meetings of the African Union, Conferences of Ministers of Health and Ministers of finance conferences, sessions of WHO Regional committee for Africa, and several High-Level Health financing panels (Kampala, July 2010; Ethiopia, March 2011, Yamoussoukro, Sept 2012). These could have served as constant reminders to governments to increase investment in health. We however need to pay attention to the Abuja commitment criticism that has been raised several times regarding the appropriateness of the set percentage.  Some have raised the issue that even if this is met, per capita investment in health will still be low while others have stated that these commitments are not feasible in the overall budgeting framework of a country.  The minister of finance of Sierra Leone, in one of the panel discussions, presented a scenario where government commitments in terms of percentage allocation to the different sectors exceeded 100%.  This could explain the stagnation or even a decrease in some of the countries.

There is a category of countries which registered significant increase in “General Government Expenditure” as a percentage of “Total Health Expenditure” which could be partly explained by a renewed vision on health in several ways.  Here we note for example Ghana, Ethiopia, Uganda and Rwanda.  These are countries that moved into Sector Wide Approaches (SWAps) where a clear vision was articulated, donor support harmonized and aligned to sector plans, delivery mechanisms streamlined and agreed between governments and partners and monitoring sector performance strengthened and made more inclusive.  Instruments to guide implementation of health programmes under SWAps were developed (for example memorandum of understanding) that had commitments for all partners.  Successes of this approach were documented for example in Uganda by Ortendahl.  This could have portrayed the sector as more organized with a clear strategy and thus increase in investment by the government, but also in an effort to meet their commitment as laid down in guiding documents.

Some countries that registered decreases in health expenditure as a percentage of total government expenditure registered increases in contribution of external sources.  For example, Sierra Leone, Eritrea, Kenya, Namibia and Swaziland are the countries in this category.  The extent to which a replacement effect explains this phenomenon, where increases in external sources result into reduced investments from government resources, cannot be fully answered with available evidence, although it is a possible explanatory factor.

The future of domestic resources as a significant source of financing will depend to several: 1) the ability of countries to generate local revenue 2) strengthening administrative systems of tax collection and 3) political will to invest in health.

Lagarde and Palmer that you quoted in your article found increases in health service use when quality improvements were introduced at the same time as user fees. Could this be a good option/argument to maintain user fees so as to avoid resource gaps in health services delivery?

The high OOP for health remains an issue of concern given the negative consequences that have been a subject of debate for a long time.  Some people have argued that if quality of care is going to be improved then perhaps user fees are not as bad as portrayed. 

In our view, maintaining use fees because of possible quality improvements may not be a good option for several reasons. When we look at available evidence, where quality has been improved alongside user fees, these have been pilots or action research settings. Given the controlled nature of such demonstrations, intensified supervision and rigorous monitoring, implementing such a scheme at national level would be very costly.  Regarding closing the resources gap, evidence has shown that in majority of settings the ability of OOP to achieve this is limited.  Given the high OOPs for health in majority of countries in the African Region, exploring how this can be channeled through prepayment mechanisms is one of the options.  One other issue that has not received adequate attention in the debate of reducing OOP payments is the role of the private sector.  A significant percentage of the population, the poor included, seeks care in the private sector where costs are high and quality of care not guaranteed.  Addressing the issue of OOP in the public sector alone is not enough to reduce OOP.  There is need for regulatory mechanisms for the private sector to control cost escalation and ensure quality of care, and provision of subsidies to enable the private sector reduce costs.

In 2006 the fifty-sixth session of the WHO Regional Committee for Africa adopted a health financing resolution that urges member state to strengthen the national prepaid health financing systems. How these prepaid systems evolved since the resolution?

Since the resolution, even prior to this, several countries have been involved in discussing and designing health insurance schemes.  Since 2000 Uganda has been discussing feasibility of introducing health insurance; which culminated in a SHI feasibility study in 2008. Kenya has been exploring expansion of the national hospital insurance fund to cover not only the formally employed but also those working in the informal sector. Burkina Faso, Lesotho, Swaziland and Zanzibar (in Tanzania) have undertaken feasibility studies. Rwanda undertook a detailed health financing review to guide further expansion of its community-based health insurance. Sierra Leone is in the stage of designing SHI scheme.  Putting in place prepayment mechanisms is one of the big challenges faced by countries in the AFRO Regions.  A lot of discussions and studies are going on but actual progress yet to be realized.

The delay on the design stage on one hand is understandable given the fact that several of the conditions that are favorable to putting in place health insurance schemes are not in place.  For example, the formal sector is only a small percentage of the population, the population is largely rural based posing administrative challenges, incomes are low and the informal sector is not very organized in several of the countries. In addition, the fact that almost half of the African Region population live below the international poverty line poses a challenge of the ability-to-pay SHI premiums.

The challenges to be overcome to start off health insurance are several, among which is the weak health systems to deliver the designed benefit packages.  This will call for specific grants to improve and expand the capacity of the system to deliver services within the package.  Administrative capacity to design and manage insurance schemes is lacking in several of the countries.  In country dialogue to reach a consensus has not been easy and the process has been a protracted debate of back and forth, for example discussions have been ongoing in Uganda since 2000, but even just agreeing on the design was only achieved in 2010.  In Kenya the process went along way, but only for trade unions, private health insurance schemes, private hospitals and others with vested interests to object signing of the SHI bill into law at the last minute.  Appreciation of health insurance and solidarity as a concept is still very low calling for rigorous awareness raising even among elite.

We however have health insurance success stories in, for example, Ghana and Rwanda. The decision of whether to start or not start a health insurance scheme is a country decision but careful attention must be paid to details in the design, development and phased implementation stages. It is critically important to develop mechanisms for diagnosing implementation bottlenecks and a plan for resolving them timeously to build/sustain confidence and trust.