My first real encounter with the Plan NACER (now renamed “Programa SUMAR”, since the expansion of the target group and the benefit packages) (1) was in December 2013, at a donor meeting on RBF in Oslo. Martin Sabignoso, the Lionel Messi of Performance Based Financing (see picture), presented the Argentinian experience to us in a very convincing way. I was therefore happy to accept an invitation by the World Bank to attend its annual “Results and implementation workshop for RBF” (25 March – 1 April) in Buenos Aires. It was time to discover the experience in the country itself. Here are my own take home lessons (2).

Commonalities between SUMAR and PBF …

The Programa SUMAR and what we call Performance-Based Financing (PBF) in Africa, have many things in common. For a start, they both seem to work. In Buenos Aires, we had the chance to listen to Paul Gertler (Berkeley University). Paul is a big name in the research community: among many other things, he proved the impact of the Oportunidades scheme in Mexico and of PBF in Rwanda. He shared his findings on the impact of the Plan NACER on several key health outcomes. The figures are impressive: the Plan reduced the number of babies with a low birth weight, by increasing prenatal care use and quality; combined with better care for low birth weight babies, this led to a reduction in neonatal mortality among the scheme beneficiaries. One of the most interesting results is the reduction of the inequity in terms of health status across provinces: the poorest ones have caught up with the average in terms of infant mortality rates. The strategy is also very cost-effective.

Another similarity between NACER and PBF is the transformative power of the strategies – a feature which is growingly recognized as a key strength of such schemes. In Argentina, this could be seen at many levels. For instance, the program accelerated the adoption of ICT in the health system. Another nice example is the fact that NACER transformed the public health subsystem from one to which people were implicitly belonging (free health care) and implicitly covered (no list of health care services) into a system with formalization of the entitlement (people have to enroll in the program) and an explicit package of health services (Plan NACER Health Care Package). This has forced the public subsystem to collect names of people, which is seen as an important step in the development of a close relationship between the system and each eligible household. (3)

More fundamentally, it has demonstrated to the rest of the health administration the importance of focusing on results. During the field visit, I asked Claudio Scalamogna, general coordinator of the Programa SUMAR in the Province of Chaco, whether the new style of management brought by the Plan could one day penetrate other social sectors. He answered “This is my dream”.

A last similarity I want to highlight is the narrative used to present the scheme. When one listens to Martin, you get the impression you’re listening to a PBF champion. This is of course interesting, as both strategies developed in parallel and independently. I asked Martin how he explains this; his answer was straightforward: “Results Based Financing is about human beings, how human beings can improve their work, and how we, as policy makers, can empower the health workers towards a prioritized goal. Our assessment in Argentina was that in order to improve health of the under-covered population, we had to redesign incentives to health facilities, improve work conditions, give autonomy, provide opportunities for training and for greater participation in the health system. We think that is the secret and I am not surprised it applies to other countries as well”.

But the differences are even more interesting…

A first difference: Argentina is a federal state and the Programa SUMAR reflects this reality. The program rests on a two-tier contractual system: there’s one contract between the national level and each province and another one between the province and health facilities. The contract between the central government and the province has two components: 60% is paid on a capitation basis (in 2013, around 2.6 US$ per person who has registered for the SUMAR– but existing enrollees count only if they used at least one health service during the last 12 months), 40% is performance-based using tracer indicators (see below). Initially, the whole funding was coming from the national level (with money from a loan granted by the World Bank). But since 2009, the provinces have also been co-financing the program, up to 15% nowadays. This share is expected to grow further. Martin told us that an efficient trick to keep control over such a two-level system is to use the national funding to remunerate the provincial unit teams. This allows the central level to define the profiles of members of the provincial units and to have a say on recruitment by provincial units.

The national government maintains some key decision rights: it defines the list of health services that are covered under the program (the benefit package) and the categories of costs which can be covered at facility level with the revenue collected from the program. But the rest is under the control of the province. For instance, each province defines the fee to be paid to the health facility for each service. While the program´s rules stipulates that facilities are allowed to allocate to staff incentives up to 50% of the program revenue, it is up to  each province to decide whether that percentage will be 0 or 50. Of course, below the province, the health facilities are also granted key decision rights: thus the facility has the final decision on what to purchase (but with a variable degree of autonomy across provinces, as we could observe during our visit). We were told that in general, health facilities are prioritizing training opportunities, equipment and infrastructure improvements.

A second difference: more complex payment formulae

The National government puts the emphasis on 14 key interventions scientifically proven to have an impact on priority health problems. As quality is key for the effectiveness of these interventions, a lot of stress is put on fulfilling quality conditions. According to this principle, a province receives more resources as long as its performance is above defined targets. For example, if the province manages to give a first prenatal check-up before the 13th week to at least 29% of the eligible pregnant women, it will receive additional resources. The higher the percentage of women with early check-ups, the higher the retribution (It is a continuous payment function). Each tracer has a mandatory set of information regarding the quality of the health service to be reported for every case. For our example, the province must report – along with the name of the woman and her ID number – the  date of the first check-up, the week of gestation, the date of the last menstrual period, the probable date of birth and, of course, the name of the health facility that provided the health care.

The contract between the Province and the facilities is simpler. They are paid on a fee-for-service basis (a price per quantity, as in PBF systems). For a selected set of health services they have also an incentive to match some standards for quality. All of this is subject of ex post verification (see below). Additionally, some provinces are using higher prices for health services that fulfill the quality matrix. In this case, they are extending the sanction scheme post verification in order to penalize the cases that do not match these criteria.

I  discussed this approach with Gyuri Fritsche (World Bank). He reminded me that this approach – to pay for an output only if it has some key attributes of quality – was the initial strategy of the Belgian Technical Cooperation project in Rwanda (except that the BTC verified the fulfillment of quality attributes ex ante). This model had not been adopted for the scale up in Rwanda and elsewhere in Africa, as it was considered too difficult to bring to scale: collecting quantity and quality indicators separately was seen as much easier to implement – the former being collected monthly, the latter quarterly. The Argentinian system is indeed much more demanding in terms of routine data collection, but as we know, there is an ICT revolution going on. This is something we may have to reconsider in the future.

A third difference: allocation of the RBF revenue to individual bonuses is not the dominant model. Only seven out of twenty four provinces allow their facilities to pay incentives to the personnel. Martin told us that several reasons explain this heterogeneity. Some provinces do not want it for legal reasons, others because they don’t think direct incentives to personnel will bring better results; some also doubt they would be able to sustain a bonus scheme in the future. As a matter of fact, in the health centre we visited, the transfer received from SUMAR represented just 4% of the health centre wage bill. Not sure this would be enough to induce a dramatic change.

We were of course curious to know whether there was a difference in performance between the provinces which have allowed facilities to pay a bonus with the funding and those that haven’t. I asked the question to Paul and Martin. Paul explained that the outcome variables he used to prove the effectiveness of the NACER plan were very rare events; the sample sizes unfortunately did not allow to ascertain a possible positive contribution of individual bonuses. He is about to check this possible determinant with another data set. Martin’s assessment was that the main determinant of the surge in performance has been the  expansion of autonomy at facility level: to have resources and be free to allocate them. As he put it nicely: “Health facilities have set up collective management approaches. RBF represents a real change in the culture of the health system, including at health facility level. For the first time health staff are participating in allocation decisions. This is also incentivizing!” The staff of the health centre we visited gave us another (complementary) explanation: the economic crisis of 2001 was really terrible and the health system experienced a collapse. The reinjection of funds brought by the NACER plan and the fact that the health facility staff had decision rights was a relief and created a new dynamic.

A fourth difference: a more important role for external verification. In PBF schemes, external verification is mainly there as a mechanism to reassure sponsors about the reliability of the verification system; it is henceforth called ‘counter-verification’. The External Concurrent Audit in Argentina is more integrated in the general functioning of the RBF scheme. For instance, the information gathered by the external audit firm feeds into the supervision program of the internal auditors. The permanence of the external audit allows the internal audit to focus on supervision, coaching and problem solving. This is something very valuable as this allows the program supervisor not to be perceived as controller. In Argentina, the external audit’s decisions have biding authority: if a discrepancy from the rules is found, no interference by authorities is possible: the penalty will have to be paid. This external audit is costly, but interestingly enough, the fines it charges to health facilities are nearly covering the full cost of doing the external audit.

A fifth difference: the management of Programa SUMAR involves a lot of people. Olivier Basenya (Ministry of Health, Burundi) and I were a bit shocked by the numbers mentioned when we heard them for the first time in Oslo: 150 staff at the national office of the program and 700 for the whole country! Compare:  Burundi’s central level PBF team counts only 7 ministry of health staff and 3 staff affiliated to partners. Are too many people involved in SUMAR management?

As explained by Martin: “Our job is to develop the strategic planning, to provide support and to supervise the 7,000 health facilities involved in the program. We are also administrating the 24 legal performance contracts. Our team is therefore multidisciplinary: we have economists, physicians, lawyers, social psychologists, experts in communication, experts in information technology, accountants… Health progress is multi-causal, so you need to build multiple solutions, multi perspective solutions. We are always fine-tuning the strategy, trying to learn what the reality is saying to us. We are also very committed to training the provincial teams. SUMAR is also a program that integrates all other substantial programs. We are working with more than 30 health programs in our Ministry of Health”.

We also noticed  many medical doctors in the health center we visited (well, most were absent, but they were reported as members of the team). So, it is possible that the relatively large team of the SUMAR program partly reflects a context-specific reality, but we agree that some PBF national units in Africa could be strengthened.

A last difference:  the system is steered more dynamically

A big danger with a PBF system is self-satisfaction:  you set up the system and then you run it more or less in a routine way. At the workshop, I checked with Olivier Basenya about his main take home message, and he duly agreed: “the Argentinian national unit steers its RBF system in a more dynamic way than we do”.

To conclude

Argentina was a refreshing experience for many PBF experts. Let’s keep in mind that RBF is not about implementing a single standard model. Although there are principles and good practices, there might be even better practices out there that we still have to discover. We learned a lot from Argentina during our stay in the country. Conversely, the Argentinian team is also eager to learn from other country experiences, so don’t hesitate to invite Martin.

(1) In this text, I refer to “NACER” when I refer to the initial scheme. I use “SUMAR” when I refer to what is in place today.

(2) I express my sincere gratitude to the SUMAR team, and particularly Mrs Jesica Azar who kindly answered my numerous questions on the way to the health center.

(3) I find this idea interesting and could be considered in some African countries. Let’s illustrate the concept with the case of Burundi. Each child under 5 would still receive treatment for free, but the health centre would be reimbursed by the national PBF scheme only if the health centre can provide for each utilization by a child his ‘free health care’ number. The great benefit of such a model is that it incentivizes health facilities to enroll families in the program, a way to develop a stronger bond with them. I also imagine that our ICT/PBF colleagues could develop solutions to provide information on utilization by enrollees to health centres (lost in follow-up, etc) to improve continuity of care.

Jean-Benoît Falisse


Dr. Walter Kessler worked for Doctors Without Borders - Belgium (MSF) in the 1980s. Together with Eric Goemaere, he was one of the architects of the of the ‘health stores’ project, an experience that had greatly inspired the Bamako Initiative as the project was based on both cost recovery and community participation. Later on, Walter also worked on the implementation of the Bamako Initiative in Chad. He discusses these two experiences.

Can you start by telling us about the first project in which you were involved in, the “health stores"? What was the idea? In what context did it occur?

In 1984, during an exploratory mission in the sixth region of Mali (Timbuktu) and after several years of drought, MSF discovered a situation that was critical in every respect: socio-economic, sanitary, and food-wise. The decision was then taken to intervene and two things were set up: (1) a supply system of essential medicines for the health system; and (2) feeding centres for malnourished children. The centres were quickly operational and ran rehabilitation and nutrition education programmes. They also integrated other routine activities of the health centres. But it was not enough. Without massive food aid, the situation could only get worse. In a context of persistent drought, the population had exhausted all forms of food reserves, including seeds.

Events then precipitated: the donors came forward and MSF quickly became a major player in the widespread distribution of grains in the form of food-for-work activities. Food was given out in compensation for work that was organised following various community initiatives, such as the repair of water dykes or the rehabilitation of schools and health clinics.

To support food aid and the drug supply system, MSF also implemented a strategy of "health and drought stores". The idea was to create points for the supply of different basic items such as seeds, spare parts for irrigation pumps, or essential medicines for hospitals and clinics. It would then establish a buffer, a capacity of resilience of the supply system. This system had to be sustainable and a cost recovery approach was therefore chosen. "Stores" would sell their products.

What did the health stores bring new?

In fact, there first was a transition from the emergency "health and drought stores" to the "health stores". These structures were supposed to supply dispensaries and hospitals, given that the already existing “people’s pharmacies” could not do that anymore.

Health stores were accompanied by several innovations, at the medical level first:

• The concept of essential drugs was something new. The list of products used was that of MSF. The “people's pharmacy”, which was the traditional supply system, proposed wholesaler packages for some molecules, but shortages were common. Hence the import of stocks of drugs for the 5th and 6th and health region.
• Similarly, trainings on the use of essential drugs (prescription, dosage, etc.) were organized for the medical staffs.
• A system for recording visits was set up and operated at the health facility-level. Indeed, the rationale for the use of drugs should be based on the morbidity encountered.

And what was new in terms of health services management? Did community participation originate in food-for-work activities?

Yes, building on community experiences during the food-for-work emergency phase of 1984, MSF set up the first health committees Mali. In fact, we transformed the food-for-work and nutrition committees into committees around the health centres, each covering a catchment population. The committee was supposed to be involved in the management of the stock of medicines and ensure the proper use of the means available at the health centre-level. It was composed of members of the community.

Community participation was an opportunity created by the extremely precarious situation in which the population was. Food-for-work was addressed to communities and was thought of as compensation against work for the common interest. This approach enabled us to achieve the rapid distribution of a large quantity of food to the final recipients. The flexibility of an organization like MSF has probably improved the efficiency of the system, but at the same time, public structures were partially bypassed. This caused frictions but the inclusion of district chiefs and village health workers in the health committees helped us avoid problems. The involvement of the whole community, including the medical staffs and authorities, in the project allowed everyone to save face.

How did the health store strategy work? How was the idea received by the population?

This system quickly proved efficient in terms of drug supply. The pyramid –one store per region, and then stores at the lower level (the “cercle”) that cater for health centres– was effective, and so was the procurement system that was flexible and required only limited consultation with some suppliers known for their reliability. Through the new system, out of stocks stopped.

On the ground, there was no visible problem with the acceptance of health stores and this especially because of the situation; who would dare to question a program that caters effectively for an entire area in an adverse socio-economic context? Conversely, it is difficult to say whether all the actors really supported the concept. It is likely that the administration of Public Health was divided on the issue: on the one hand because it disavowed the existing system and on the other hand because of the too important place of MSF in the implementation and management.

Obviously, the speed of implementation and the effectiveness of the system aroused the curiosity of other donors and international organizations. Given the situation, the involvement of the population was -among others- opportunistic, but it fit perfectly with the concept of Primary Health Care advocated at the Alma-Ata conference.

Later on, the Bamako Initiative was inspired largely on the "success story" of health stores. Its founders believed that with this strategy, health for all by the year 2000 was at hand. However, we were quickly disillusioned. At the time of the Bamako Initiative, the health stores had not gone through their “sickness of youth” and it was unclear whether the concept as such, partly based on community participation, was actually viable in the medium and long run.

Based on your experience, do you feel that community participation was ‘spontaneous’?

In times of scarcity and famine, when everybody first works for their own survival and the survival of their relatives, community participation could never be spontaneous. Similarly, in a less dire situation but still marked by relative poverty, community participation without an immediate benefit for oneself or one’s family seems illusory.

Community participation had been requested to facilitate the delivery of aid and then organize the management of health activities. I think this participation was neither entirely spontaneous nor completely imposed. It was naturally organized around the revitalization of health facilities. With food-for-work, nutritional rehabilitation, and the supply of drugs, the benefits of participation were immediate and visible.

Let's talk about your experience in Chad. What were the differences with Mali?

MSF had already begun the supply of essential drugs to Chad during the civil war in the 1980s’. Our activities were gradually extended over a large part of the territory until the mid- 90s’ (I left Chad in 1995); there was a very serious shortage of skilled medical staff. Driven by the circumstances, MSF became a major player in the health pyramid, and was completely integrated to it.

The establishment of community participation in the prefecture of Mayo-Kebbi in 1989 took place in the context of a larger project of revitalization of the entire health system that included the rehabilitation and extension of infrastructures, the revitalization of district hospitals, and support in medical supplies and staff training. From the outset, community participation was oriented towards the active participation of the population in the management of health centres. This management was mainly about the revenues generated through curative consultations in order to cover the cost of medicines.

Revenue management was provided by a person designated by the health committee. This system was encouraged and supervised by the head doctor. The remoteness and lack of competence in the field did not allow for other alternative for the management of relatively large amounts of money; direct management by the medical staff was not a credible alternative. Revenue management remained risky because there often was no way to deposit money outside the health facility.

In an interview on this blog, Agostino Paganini declared that the Bamako Initiative died long ago. What is your take on that?

It is impossible for me to know what our projects have become, especially against the background of the tragic circumstances the region is going through. However, it seems that community participation as conceived in this time is fragile and transient. The heavy investment that is needed for community mobilization and voluntary participation to the committees is hard to sustain and inevitably leads to the depletion of the initial enthusiasm. The “bureaucratization” of some positions in the committees, such as treasurer or manager, often announces the beginning of a general decline in community participation.

In situations I have experienced in countries facing socio-economic and / or political stability and security issues, participation is not spontaneous and does not originate in local initiatives. It is rather part of intervention and support strategies, it is genuine good intention but it is not necessarily in phase with the problems of the target population.

Community participation, as long as community mobilization is supported and regular, can be an interesting vantage point to address populations’ need and take action. Yet, the survival of such initiative is directly related to the duration of the projects/interventions.

Yamba Kafando


From November 25-28, 2013, a workshop on maternal health fee exemption policies is being organised in Ouagadougou (Burkina Faso). Its objective is to draw conclusions on such policies through research results and the experiences of key actors. 

For more than a decade now, a number of African countries have been implementing national fee exemption policies targeting certain services (HIV, malaria, deliveries, Caesarean sections, etc…) or specific population categories (children under 5, pregnant women, the elderly, etc…). The objective of most of these policies is to increase chances of reaching the MDGs and also to reduce financial barriers to accessing health care.

If there is one major shortcoming, however, it is that most of these policies were hurriedly implemented, began on a national scale without a pilot phase, and worse, without having designed or put in place any evaluation mechanisms to measure their effects.

Knowledge on fee exemption schemes: much production, but too little sharing and utilisation

Such highly political processes and hasty implementation present clear methodological challenges to those who wish to evaluate fee exemption schemes. And yet, many different research programs have undertaken studies on the subject and their results are now starting to become available. A number of NGOs have documented their fee exemption interventions. Managers of fee exemption schemes and front-line implementers also have important tacit knowledge that should be shared.

One common characteristic of the period in which these policies were implemented (2000-2010), is that there existed no platform in place for exchange and knowledge management among implementing countries. No doubt this at least partially explains why technical and scientific knowledge already available at the time was rarely used to improve fee exemption policies, leading to a cycle of repeating the same avoidable mistakes.

This situation did, however, lead people to realize the importance of creating such a platform for knowledge and experience sharing, and as such, the Financial Access to Health Services Community of practice (FAHS CoP) was launched.

A more scientific workshop

So it is with great pleasure – and we think a fair amount of legitimacy, that the FAHS CoP announces the upcoming workshop in Ouagadougou dedicated to the evaluation of maternal health services fee exemptions in Africa.

Many of you will remember the one held in Bamako in November 2011. With this upcoming, and most likely last CoP workshop on the topic, we feel confident we can close this chapter of knowledge production.The Ouagadougou workshop will be more scientific than Bamako was: it will allow us to highlight and share the knowledge created through studies carried out on maternal health fee exemptions by different research consortiums, including those linked to the FEMHealth project, the University of Montreal and the University of Heidelberg.

The workshop aims to bring together countries implementing maternal health fee exemptions with research teams who have been investigating these policies in Africa. The goal of this workshop will not be to judge the choices countries have made regarding maternal health fee exemptions, but rather to help them to make them more effective and efficient so as to improve the health of their populations.
 
In order to facilitate a maximum of exchange, a call for abstracts covering 10 themes has been issued not only for researchers, but also for managers and implementers of such schemes. We would like to invite you to share your experience on the topic through this blog, and also by submitting an abstract for the Ouagadougou workshop. On behalf of the Institute for Health Sciences Research (Ouagadougou), we look forward to welcoming you to Burkina Faso.

(Translation: Allison Kelley)

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.

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.