COMMUNITY FINANCING OF HEALTH-CARE IN AFRICA - AN EVALUATION OF THE BAMAKO INITIATIVE

The Bamako Initiative, a controversial attempt to strengthen Primary H ealth Care using community financing and community participation and m anagement was launched at a meeting of African Ministers of Health in 1987. This evaluation focuses particularly on the community financing aspects of the initiative. Previous experiences of community financing highlight particular lessons for the development of the initiative an d issues likely to be encountered in implementation attempts. Four cou ntry case studies of the Initiative at its early stages of implementat ion (in June, July and August 1991) were conducted in Burundi, Guinea, Kenya, and Nigeria. Similar activities in Uganda were also studied. T hese were short studies of one month each and utilised methods of rapi d evaluation. The studies aimed to direct implementers quickly to issu es requiring attention rather than to reach overall conclusions regard ing the success of the Initiative which would be premature at this sta ge. Price structures used by the Initiative need to consider the acces s of marginalised groups more than is the case at present. In addition , there is a need to ensure against over-prescription and commercialis ation and to ensure that incentives for utilising most appropriate lev els of care are maintained. The evidence suggests that most people do find amounts of money to pay for health services which are large in re lation to their income. This is probably a tribute to extensive commun ity support mechanisms. Nevertheless, it highlights the plight of thos e who fall through this safety net for whom even charges for very basi c care may be prohibitive. On the other hand, it appears that in most cases, the Initiative's activities provide a service which is cheaper when all costs to the household are taken into account, than was avail able before. The quality of services included in the Initiative's acti vities in the five countries was highly variable. Success in raising s ubstantial revenues has also been mixed. In some countries however, su bstantial funds have been generated and used to achieve real improveme nts in health services. Overall, the experiences of the five countries appear to have been highly dependent on a number of 'environmental' c haracteristics: a tradition or not of 'free' services; the adequacy of current resource availability and that immediately preceding the intr oduction of the Initiative; the existing stage and nature of decentral isation within the country; and the competition the Initiative's activ ities face with alternatives.