26 World Health • SOth Yeor, No. 5, September-October 1997 The Initiative Kasa Asila Pangu

The Initiative launched in 1987 in the capital of has proved to be an effective strategy for improving the quality of health care for most people, as well as their access to it.

• state participation to ensure that the whole population can have a minimum package of servi ces, selected for their cost-effective­ ness; • rationalized and decentralized implementation of programmes at the level of the di strict health system.

The most striking result of applying these principles is the increased use made of preventive and curative services. In some countries, like A minimum package of effective services, including immun ization of children, can rapidly improve and , the numbers of the health status of the population, even in difficult economic conditions. Photo WHO/ UNICEF / H. Davies fully immunized children had fallen to very low levels a few years ago. deteriorating economic situa­ encouraged a disorderly growth of The countrywide extension of the tion and structural adjustment the private and informal sectors, Initiative enabled immunization Apolicies in many countries of with dealers in drugs and injections coverage to grow steadily. As a sub-Saharan have helped to offering health care of dubious result, the percentage of fully immu­ cause a slump in spending on social quality at high prices. ni zed children rose from 16% to services, and on health in particular. The Bamako Initiative was 75% in Guinea and from 24% to Even in countries that have suffi­ launched in 1987 in the capital of 80% in Benin between 1985 and cient resources, poor management Mali by the health ministers of 1995. These results were obtained and bias in favour of centralized African countries at a conference by the health centres and did not services and large hospitals mean sponsored by WHO and UNICEF require the support of mobile immu­ that most people who live in the with the aim of ensuring that the ni zation teams. The use of prenata] countryside or on the fringe of the entire population should have access consultations also rose to a similar big cities are deprived of basic care. to primary health care of good qual­ degree. To make matters worse, there is ity at an affordable price. The little public participation in the Initiative is based on the following Preventive care decision-making process, and a principles: tendency to launch programmes with • public participation in deci sion­ The steady growth in immunization short-term goals which do not favour making; coverage in countries or districts participation. As a result of the crisis • contributions by users to finance applying the principles of the in the health sector, the general the health centres so as to cover Initiative has resulted in a big reduc­ population has a very poor opinion the running costs and improve tion in the diseases concerned. of the public services. This has both quality and access; , for example, during the World Health • SOth Year, No. 5, September-October 1997 27 two years preceding its civil war, did not have a single case of indigenous measles. Moreover the resources generated and managed locally by village communities have made it possible to extend coverage with preventive care to remote areas. The rates of curative consulta­ tions have also improved. In the central region of , for instance, the consultation rate was very low and see-sawed up and down depend­ ing on the arrival of drugs. The revitalization of the health centres involved training the staff, organiz­ ing an efficient supply of generic essential drugs, and introducing community control of the manage­ A mother and child health team on ifs rounds in . Bringing core to remote places is one of ment. The frequency of consulta­ the challenges of the Bamako Initiative . Photo WHO/UNICEF / G Pirozzi tions tripled or quadrupled in some health centres immediately after they were restructured, and has remained leprosy and tuberculosis, which is cap and cultural barriers also con­ stable throughout the year. often subsidized by the state. tribute significantly to excluding the In Mali, after reform of the health To improve access to curative poor from health care. districts, there has been a big in­ care, systems of payment now in­ Thanks to the introduction of crease in the numbers of emergency clude exemption, pre-payment, generic essential drugs, to the ratio­ cases transferred to the di strict post-payment and health insurance. nalization of services and particu­ hospitals, particularly pregnant Hitherto none of these systems were larly to greater community control of women with obstetric complications. used on a large scale in sub-Saharan the running of basic health services, Here the activities include improv­ Africa. In the central region of Togo, the Bamako Initiative has proved to ing the running of community health the method applied by the health be an effective strategy for improv­ centres, ensuring a better quality of committees is to compare the pro­ ing the quality of health care and emergency obstetric care at the portion of patients exempted from access to it for most people. If the district hospital and, above all, payment at their health centres with poorest of the poor and communities entrusting the community health the equivalent proportion at the local in remote areas are to benefit fully associations with the responsibility missionary dispensary, where the from the health care that is their of improving management and nuns in charge are dedicated to right, this will certainly require an transport. Thanks to the contribu­ treating all the population, including additional effort of solidarity on the tions made by the health associations the very poorest. At their dispensary part of governments, as well as the and the hospital towards the man­ between 10% and 15 % of patients do introduction on a much larger scale agement and running costs of an not have to pay. These rates are of systems for sharing financial ambulance, the patients pay only a accepted as a reference point by all risks, such as health insurance. But modest sum for being taken to hospi­ the other health centres, which try to in no case should this assistance tal and the ambulance is perma­ keep their own rates at thi s level. prevent the decentralized services nently available. Another interesting experiment and the communities themselves was undertaken at the Dioila from being imaginative and adopting Hospital in Mali, where patients solutions that affirm their resolve to Reaching the poorest of the with urgent problems are treated at help and serve the poorest members poor once from a reserve stock of drugs of their community. • and equipment established expressly In remote areas where everybody for this purpose. They are then lives on the verge of poverty, it is not invited to settle their bills after easy to provide health care for the treatment. Contrary to what might poorest of the poor. But today it is have been feared, the rate of recov­ clear that the preventive care offered ery of the costs exceeds 95%. free and in a decentralized manner is Of course, the cost is not the only benefiting the entire population. obstacle preventing the very poor Dr Kasa Asila Pangu is Senior Adviser, Development of Health Systems, United This is also the case for the treatment from using health services. Nations Children's Fund {UNICEF}, 3 United of certain chronic diseases such as Ignorance, physical or mental handi- Nations Plaza, New York, NY I 0017, USA