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HEALTH POLICY AND PLANNING. 1990 Jun; 5(2):186-9.WHO and UNICEF joined forces to support the Bamako Initiative agreed upon by African ministers of health at a 1987 meeting. Primary health care (PHC) should be advanced by identifying and introducing self-financing mechanisms at the district level (specifically, revenue from drug sales), securing a constant supply of drugs, and promoting social mobilization. UNICEF has produced several policy papers on recurrent costs and the sales of drugs. The 1988 UNICEF policy paper Problems and Priorities Regarding Current Costs reviews UNICEF practices of financing programs and proposes recommendations. For example, about 40% of program expenditure goes to recurrent costs, especially the financing of drugs and vaccines. Another 1988 UNICEF working paper is Community Financing Experiences for Local Health Services in Africa, which reviews 3 case studies on community financing. Today, however, UNICEF no longer considers drug cost recovery as essential to the Bamako Initiative. In July 1989, the WHO Regional Office for Africa published Guidelines for the Implementation of the Bamako Initiative. Charging for Drugs in Africa: UNICEF's 'Bamako Initiative' (1989) critiques UNICEF's policy in the context of the IMF and the World Bank adjustment programs. Availability of Pharmaceuticals in sub-Saharan Africa: Roles of Public, Private and Church Mission Sectors (1989) highlights the success of cost recovery in church mission health care and the efficiency of distribution through the commercial sector. Its authors consider the Bamako Initiative to be unrealistic. One of the first shots at reviewing community financing experiences is the 1982 article, Community Financing of PHC. Other works are Financing PHC Programmes (Christian Medical Commission), Financing PHC: Experiences in Pharmaceutical Cost Recovery (PRITECH), WHO's Financing Essential Drugs, and A Price to Pay: The Impact of User Charges in Ashanti-Akim District, Ghana.
HEALTH ACTION. 1994 Jun-Aug; (9):7.The Bamako Initiative, a health reform package initiated by the World Health Organization and UNICEF at a 1987 meeting of African Ministers of Health, has reached thousands of local health centers in 30 countries with its community participation program. A central goal is to generate funds for expansions in local health services through the introduction of user fees, prepayment schemes, and revolving drug funds. The concept of community co-financing is based on local involvement in selecting target health reforms, generating income, and managing programs rather than a top-down approach where programs and user fees are imposed on a community. Health management committees at all health facilities are responsible for implementing the reforms and being accountable to the community. To compensate for the limited management skills at the grass-roots level, UNICEF's Health Systems Development Unit has developed training modules for use by these committees. It is the intention that the community participation inherent in this approach will reverse the trend toward urban, hospital-based care and vertical programs.
IPPF / WHR FORUM. 1993 May; 9(1):15-6.USAID, through the matching grant project, provided International Planned Parenthood Federation's Western Hemisphere Region (IPPF/WHR) funds to increase and strengthen family planning (FP) services in Latin America. Family planning associations (FPAs) were to match any USAID-awarded funds with other funds, supporting efforts to promote sustainability of service delivery. The matching grant was an extremely effective and efficient means to expand access to good quality, voluntary FP services to low income, underserved people. Local income funded about 33% of Matching Grant FPA budgets. USAID and IPPF or other donors shared the other 66%. The Matching Grant FPAs reached the original target of 2.8 million new acceptors. The project was so successful that USAID awarded IPPF/WHR a new 5-year (1992-97) Transition Project. In Latin America and the Caribbean, its goals are to increase people's freedom to choose the number and spacing of their children and to promote a population growth rate appropriate to each country's socioeconomic development goals by helping some FPAs to become sustainable without USAID funding. Strengthening the institutional capacity of FP programs and evaluation of their performance and impact are 2 ways to achieve these goals. BEMFAM/Brazil, PROFAMILIA/Colombia, MEXFAM/Mexico, INPPARES/Peru, APROFA/Chile, CEPEP/Paraguay, AUPFIRH/Uruguay, FPATT/Trinidad and Tobago, PLAFAM/Venezuela, and BFLA/Belize have received matching subcontracts for FP service delivery and sustainability. IPPF/WHR considers Brazil, Colombia, Peru, and Mexico to be high-priority countries, largely because they have more than 60% of the population of Latin America. About 81% of Transition Project funds will go to in-country sub-grants and on regional activities, matched on a 1-to-1 basis. 86% of subcontracts will go to Colombia, Mexico, and Peru. Technical assistance and funding are also targeted to HIV/AIDS and sexually transmitted disease prevention.
HEALTH POLICY AND PLANNING. 1992 Jun; 7(2):164-76.The basic intent of the Bamako Initiative, which is supported by African Ministers of Health, WHO, and UNICEF, was to provide longterm sustainability of primary health care (PHC) by strengthening community mobilization and using community resources, and strengthening district level health services. National government would focus on the referral system. Consideration in this article is given to important issues that have arisen since its inception in 1987, the policy framework, key components, the global action, country progress (Benin, Guinea, Kenya, Nigeria, Sierra Leone, Togo, Mali, and Zaire), key management questions, and future directions in the next decade. The Bamako Initiative has 4 key features: 1) the rehabilitation and extension of the basic health care delivery system, particularly for maternal and child health services, and including peripheral health facilities and the network of community health workers; 2) provision for affordable drugs and improved knowledge on prescribing and use; 3) appropriate financing of services for longterm sustainability; and 4) community mobilization in order to increase the effectiveness and esteem of health services and involving the community as a full partner in the decision making process. The Ministers agreed to 8 principles which would facilitate the implementation of the Bamako Initiative in September 1988, as follows: 1) national commitment to the development of universally accessible PHC services, 2) essential drug policies in agreement with the development of PHC, 3) community financing which is consistent at all levels of care for health care services, 4) substantial government financial support, 5) substantial decentralization to the district level for management of PHC, 6) decentralized management of community resources, 7) measures which ensure access of the poor for PHC, and 8) clearly defined intermediate objectives and agreement on indicators to evaluate the effectiveness. A number of issues have arisen concerning the implementation of the Initiative such as community control, equity, drug use, and the low status of health workers. Since 1988 UNICEF has established funding for national task forces and conducted 3 conferences to deal with the issues and constraints. Collaboration is important and considerable involvement has been effected by the World Bank, the African Development Bank and multilateral, bilateral, and government agencies. The most active supporter of the Initiative has been Nigeria. Key lessons are that there is a need for policy development, for support from national and local leaders, for a supportive legal system, for detailed planning, for logistics strategies and workable management, for information management, for operations research, and for balanced implementation in rural and urban areas. International solidarity is need to provide the resources to fulfill the aims.
BMJ. British Medical Journal. 1989 Jul 29; 298(6694):277-8.Under the Bamako initiative, UNICEF will provide free drugs to participating countries for the 1st few years; drugs will be sold to patients; and communities will control the finances. The aims are to establish a revolving drug fund to pay for future drug supplies and to use leftover money to maintain and improve primary health care services. Several problems with the initiative are foreseen. Firstly, charging users may reduce utilization by the poor. Although UNICEF agrees that provision of free service for indigents in necessary, systematic identification of these people may be difficult. Secondly, financing will be difficult to implement given the rarity of managerial skills and the poor quality of local supervision. The sustainability of the initiative is also in doubt. UNICEF initially proposed large mark ups on the basic cost of the drugs; now partial recovery of the cost is proposed, although how charges will be set is unclear. The question of whether services will be dependent when the free drugs stop remains to be answered. A further objection to the scheme is the almost inevitable deterioration of rational prescribing; paying patients will feel justified in demanding drugs and injections. UNICEF's solutions and strategies for implementation of policy remain vague and lack attention to detail. For instance, initial training courses aide community management of drug funds, but there is no commitment to continued support and local evaluation. Other sources of funding need to be considered. Host governments should commit to continued financial and supervisory input and to maintaining control over their own health services. Communication between staff and government should be established and maintained. Gradual and sensitive introduction, with careful monitoring of equity, utilization, and rational drug use, is essential to prevent failure of this important proposal.
BULLETIN OF THE PAN AMERICAN HEALTH ORGANIZATION. 1988; 22(4):440-6.The Word Bank Study "Financing Health Services in Developing Countries: An Agenda for Reform" is centered on a thesis of decreased government responsibility for financing health services. The study points out that more basic medical services are needed for the poor, but the aged and increased urbanization are forcing the application of more finances into hospitalization services. The World Bank study incorrectly assumes that the above problem is due to an epidemiologic polarization of rich vs. poor and that the only benefits from curative medicine are private, not societal, benefits. The proposal stemming from these assumptions financially separates curative from preventative services, regardless of its proven costliness and inefficiency. The 4 suggested specific World Bank reforms are: 1) charging fees for the use of health services; 2) provision of insurance or other risk coverage; 3) effective use of nongovernment resources, i.e. private practices, midwives; and 4) decentralization of government health services. These are interesting, although imperfect, solutions to the pressing problem of health care finance. The largest issues may be problems from the fragmentation of health services, cost inflation, and lack of effective controls--issues that are not dealt with in the World Bank study.
Lancet. 1989 Jan 21; 1(8630):162.This letter was written in defense of a November 19, 1988 editorial discussing the Bamako Initiative. The writer, who works for UNICEF, has been working, with WHO, on the Initiative for the past year. In addition, he taught and practiced pediatrics in Ghana for 25 years. He claims the idea of "free" health services has undermined traditional African practice and confused the debate about fairness and community responsibility. UNICEF and WHO feel that increased community involvement and contribution to costs will strengthen Primary Health Care and maternal and child health systems. Acknowledged difficulties of the program, such as equity, management, foreign currency, and drug orientation are being addressed. Research and experience in community financing for health in Africa is felt to provide a solid basis for proceeding with the Bamako Initiative.
[Unpublished] 1984. v, 25 p.This meeting was sponsored by the World Health Organization (WHO) with Dr. Wayne S. Stinson participating at WHOs request. The objectives of the informal consultation were: 1) to strengthen national capabilities for undertaking the costing of preimary health care and for the utilization of results for development and management; 2) to exchange experiences on the costing of PHC in different countries; 3) to discuss methodologies used for data collection at the PHC center; and 4) to make recommendations for future work. This consultation is one in a series of costing and financing meetings held by WHO since 1970. The most recent meeting prior to 1983 was an interregional workshop on the cost and financing of primary health care, held in Geneva in December 1980. Papers distributed at that meeting (which have not yet been published) suggest a need for greater understanding of costing principles and technical refinement of methodologies. Judging by the papers presented at the Nazareth workshop, costing efforts have greatly improved since 1980. Representatives from the following countries participated in the Nazareth workshop: Argentina, Botswana, Columbia, Thiopia, Gambia, Kenya, Lesotho, Malawi, Sierra Leone, Sri Lanka, Swaziland, Tanzania, Thailand, Uganda, and Zambia. Some of these reported costing studies. This report consists of a narrative description of the meeting itself followed by a commentary on some of the issues raised. There is then a discussion of Arssi Province and Ethiopia as a whole based on a 1-day field trip. Finally recommendations are given regarding the United States Agency for International Development's (AID's) further PHC costing efforts.
In: Wood C, Rue Y, ed. Health policies in developing countries. London, England, The Royal Society of Medicine, 1980. 35-9. (Royal Society of Medicine. International Congress adn Symposium Series; No. 24)Improving access to essential health care is a goal of most developing countries and donors of economic assistance. Many unsuccessful attempts have been made to help the poor through fostering a growth in production and redirecting development activities. Recently a basic needs approach dealing with poor housing, inadequate water supplies and sanitation, lack of educational opportunities, and insufficient health care, has been introduced. The goal is to encourage programs that will directly affect the poorest of the population. The current health care strategy, attempting to ensure universal access to reasonable levels of health, has profound financial implications. Initial investment costs are estimated to be about $20 per person and will probably be overshadowed by recurrent operating expenditures. Further it is believed that investment costs of new health care activities can often be financed through official or private external donors while recurrent costs will have to be met by individual countries. These operating costs are estimated to be in the US$6-15 per capita range, much higher than the US$.60 to US$2.00 range now being spent. However, voluntary organizations and individuals are spending additional funds for health care in such areas as private health care, non-prescription drugs, transportation and indigenous individuals like herbalists. The total level of spending suggests that with a reallocation of resources better care could be financed. Another consideration is that the importation of most drugs and supplies will require a country's ability to participate in a foreign exchange program. The major principles of health care finance should include establishing equity among clients in ability to pay principles, encouraging appropriate usage of health services, prohibiting policy which promotes excessively costly services, and being feasible. Part of an appropriate design of the financing system should include having operating costs born locally as much as possible. Additional specific recommendations for successful health care financing are made.
In: Rodrigues W, ed. The Third American Conference on Integrated Programmes [Rio de Janeiro, Brazil, August 17-20, 1982] Capri III. [Unpublished] 1982. 111-8.Group 1 analyzed the question: "How to organize the community and elicit people's participation?" The following items were identified as priorities: 1) previous diagnosis of the community; 2) leadership identification; 3) identification of opposition to the programs; 4) formation of a planned and systematic voluntary action; and 5) selection of human resources. In spite of considering sources at the community, municipal, state, federal, and foreign levels, the group recognizes and advises priority and emphasis to the community as the agent of its own development and therefore all efforts should be made in order to make the maximum use of all available resources. In order to increase the available sources, it is important to reach the highest potentials from all community resources, and elicit the interentity integration besides promoting campaigns for collecting resources. Group 2 developed the Community Development Methodology Pattern in response to the question: "How to organize community and elicit people's participation?" The survey, diagnosis, planning, implementation, and evaluation of the community and program should be included. Funding can be obtained from international or national agencies, or derive from the community itself. However, the ultimate goal should be the self-financing of the program. In response to the question: "How to organize and elicit people's participation," Group 3 concluded that knowledge of the community, and frankness toward the community was of paramount importance. In order to motivate and educate the community, the strategies of dissemination and motivation must be set up, including the use of popular literature, and audiovisual materials. The development of human resources is a factor essential to any program. Training must cover the working team as well as the leaders and volunteers of the community. A part of the training process is the information and experience exchange meetings held by the participants of the different programs. Coordination with agencies concerned avoids duplication of efforts, program performance efficiency is improved, and each agency's role is clearly delineated.
In: Rodrigues W, ed. The Third American Conference on Integrated Programmes [Rio de Janeiro, Brazil, August 17-20, 1982] Capri III. [Unpublished] 1982. 129-36.The Third American Conference on Integrated Programmes--CAPRI III, was held in the City of Rio de Janeiro, from August 17-20, 1982. It was attended by representatives from Maylasia, Mexico, Colombia, Peru, Paraguay, Ecuador, and Brazil. CAPRI III approved and adopted CAPRI II recommendations, to which the following recommendations were added: 1) the humanitarian character of the parasite control and family planning programs be conducted independently from any political or religious implications; 2) support is given to the "Manila Declaration," (the achievement of more effective utilization of appropriate approaches to attain the social and economic well-being of the people, through the experiences gained in the Integrated Family Planning, Nutrition and Parasite Control Project; 3) the integrated programs should be considered as an important and positive strategy of primary health care; 4) there is a need for permanent training of human resources and, with a veiw to this, courses and other activities concerning their development should be carried out; 4) it is necessary to find ways to increase the availability of financial resources from governments as well as from active involvement of the various segments of the community itself; and 5) use every effective demonstration means with a view toward obtaining an ever increasing mobilization of all possible community resources to assure continuity and development to integrated programs. In addition, the Seventh Asian Parasite Control/Family Planning Conference urges that all governments recognize the experiences gained in the Integrated Family Planning, Nutrition and Parasite Control Project; that all governments recognize the role that the project has played; that all governments recognize the catalytic role played by the nongovernment/voluntary organizations and continue to support them; that all internatioal organizations/agencies take note of the experiences gained in the Project; that all governments and international agencies reaffirm their continuing commitments to ensuring the participation of the people in the planning and implementation of the Program; that all international agencies/organizations increase their support for the implementation of all policies and programs aimed at achieving a better quality of life for the people.
Washington, D.C., Agency for International Development, 1983 May. 16 p. (A.I.D. Policy Paper)Cofinancing is a useful method of development finance that offers the potential for increasing the effectiveness of the US Agency for International Development's (USAID) resources by broadening the scope of investment opportunities beyond those that are within its singular capacity. Cofinancing is any formal arrangement under which USAID loan and/or grant funds are associated with funds from one or more different sources (private or public) outside the borrowing country to finance a particular program. Cofinancing may be used to leverage USAID resources with those of the external private sector as well as to facilitate the transfer of skills and technology. The Development Assistance Committee (DAC) of the Organization for Economic Cooperation and Development (OECD) has viewed cofinancing primarily in the context of its ability to improve the quality of assistance (additionality). Multilateral Development Bank (MDB) participation in USAID-sponsored cofinancing arrangements should generally be in the form of at risk lending as a means of enhancing the prospects for additionality over the medium to longer term. While USAID in appropriate conditions is willing to provide relief, it will not generally link its loans to those of other cofinancing participants through the use of mandatory cross-default clauses but may use optional cross-default clauses in the case of private lenders. In addition to advantages in the application of development assistance resources, cofinancing offers the potential for enhancing the effectiveness of USAID's policy dialogue with the respective less developed countries (IDCs). Although cofinancing has a number of potential advantages, particular care should be exercised to insure that cofinancing does not become an end itself, but rather remains a mechanism among other alternatives to be utilized when it represents the most efficient application of USAID resources in the context of the development objectives of country-specific strategies.