Our series related to the 25 years of the Bamako Initiative is slowly approaching its end. We have invited Sophie Witter (University of Aberdeen) to share some reflections on the Bamako Initiative. In the weeks to come, Jean-Benoît will present two last interviews (scoop: we have found one of the unknown fathers of the Bamako Initiative, who by the way, will answer some of the questions raised by Sophie Witter). Jean-Benoît will conclude the series with his own synthesis.
As the anniversary call says, the Bamako Initiative of 1987 focussed on two ideas: (1) the introduction (or formalization) of user fees and (2) community participation in resource management, including essential drugs which were now sold to users. While charging may have been a necessary response at the time to collapsing public expenditure in the social sectors, there has always been something peculiar to me about the linkage of these two ideas – charging for services, and community participation.
Over the years and decades which followed, the two seemed to become conflated, such that charging people equated to their participation. If people were not made to pay, they would therefore somehow be denied the right to participate in managing public services, or so the thinking went. But why? I would say that:
1. Management involvement is an independent variable – if you want people to join committees, or influence priorities or join in community activities, go ahead, that is great. Whether they are paying for services has no bearing on that issue. Where services are publically funded, the users are still tax-payers and citizens. They have just as much right to influence the way that services are delivered.
2. If you have to charge for services because you do not have enough funds, say it straight. Recognise that it is a necessary evil, which will hopefully be temporary. Don’t dress it up with some imagined benefits of community participation.
3. If participation is such a good thing, why is it confined to poor areas and poor populations? The Bamako Initiative focussed on rural districts, which essentially were the ones which were not receiving much public funding. So those who could least afford to pay were paying, while urban areas could turn to better funded hospitals, which they were not expected to run.
4. We need also to recognise that getting involved in resource and other management functions has very real costs for the participants. Those who you might most want to be represented have the least time to spare. The poor and especially women are time-poor – struggling to survive, working, trying to finding time to bring up their children.
5. Finally, community participation – which, if done sensitively, can be a valuable tool to increase provider accountability – needs to work alongside proper supervision, regulation, and setting the right incentives for facilities and staff. If the local public health care system is based around making money from selling drugs and charging fees for services, as it was under the Bamako Initiative, then no amount of users’ committees will be able to protect the patients from abuse.
So as we look back on the Bamako Initiative, let’s reflect on some of the muddled thinking that went with it, and be glad that we are moving into an era where there is a greater commitment, nationally and internationally, to move towards universal coverage, with greater public funding of essential health services. Let us also confront the challenges of achieving greater accountability of providers and real participation - not the kind that meant having to pay if you wanted your child to survive.