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Community financing of health care in Africa: An evaluation of the Bamako initiative

Author

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  • McPake, Barbara
  • Hanson, Kara
  • Mills, Anne

Abstract

The Bamako Initiative, a controversial attempt to strengthen Primary Health Care using community financing and community participation and management 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 and issues likely to be encountered in implementation attempts. Four country case studies of the Initiative at its early stages of implementation (in June, July and August 1991) were conducted in Burundi, Guinea, Kenya, and Nigeria. Similar activities in Uganda were also studied. These were short studies of one month each and utilised methods of rapid evaluation. The studies aimed to direct implementers quickly to issues requiring attention rather than to reach overall conclusions regarding the success of the Initiative which would be premature at this stage. Price structures used by the Initiative need to consider the access of marginalised groups more than is the case at present. In addition, there is a need to ensure against over-prescription and commercialisation and to ensure that incentives for utilising most appropriate levels of care are maintained. The evidence suggests that most people do find amounts of money to pay for health services which are large in relation to their income. This is probably a tribute to extensive community support mechanisms. Nevertheless, it highlights the plight of those who fall through this safety net for whom even charges for very basic 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 available before. The quality of services included in the Initiative's activities in the five countries was highly variable. Success in raising substantial revenues has also been mixed. In some countries however, substantial funds have been generated and used to achieve real improvements in health services. Overall, the experiences of the five countries appear to have been highly dependent on a number of 'environmental' characteristics: a tradition or not of 'free' services; the adequacy of current resource availability and that immediately preceding the introduction of the Initiative; the existing stage and nature of decentralisation within the country; and the competition the Initiative's activities face with alternatives.

Suggested Citation

  • McPake, Barbara & Hanson, Kara & Mills, Anne, 1993. "Community financing of health care in Africa: An evaluation of the Bamako initiative," Social Science & Medicine, Elsevier, vol. 36(11), pages 1383-1395, June.
  • Handle: RePEc:eee:socmed:v:36:y:1993:i:11:p:1383-1395
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    Cited by:

    1. Gilson, Lucy & Mills, Anne, 1995. "Health sector reforms in sub-Saharan Africa: lessons of the last 10 years," Health Policy, Elsevier, vol. 32(1-3), pages 215-243.
    2. Dr B C Purohit, "undated". "Structural Adjustment and the Health Care Sector in India: some policy issues in financing," QEH Working Papers qehwps02, Queen Elizabeth House, University of Oxford.
    3. Magnus Lindelow, 2004. "The Utilization of Curative Health Care in Mozambique: Does Income Matter?," Development and Comp Systems 0409057, University Library of Munich, Germany.
    4. Ardeshir Sepehri & Robert Chernomas, 2001. "Are user charges efficiency- and equity-enhancing? A critical review of economic literature with particular reference to experience from developing countries," Journal of International Development, John Wiley & Sons, Ltd., vol. 13(2), pages 183-209.
    5. Gnawali, Devendra Prasad & Pokhrel, Subhash & Sié, Ali & Sanon, Mamadou & De Allegri, Manuela & Souares, Aurélia & Dong, Hengjin & Sauerborn, Rainer, 2009. "The effect of community-based health insurance on the utilization of modern health care services: Evidence from Burkina Faso," Health Policy, Elsevier, vol. 90(2-3), pages 214-222, May.
    6. McIntyre, Diane & Thiede, Michael & Dahlgren, Göran & Whitehead, Margaret, 2006. "What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts?," Social Science & Medicine, Elsevier, vol. 62(4), pages 858-865, February.
    7. Adomah-Afari, Augustine & Chandler, Jim A., 2018. "The role of government and community in the scaling up and sustainability of mutual health organisations: An exploratory study in Ghana," Social Science & Medicine, Elsevier, vol. 207(C), pages 25-37.
    8. Miloud Kaddar & Friedeger Stierle & Bergis Schmidt-Ehry & Anastase Tchicaya, 2000. "L'accès des indigents aux soins de santé en Afrique subsaharienne," Revue Tiers Monde, Programme National Persée, vol. 41(164), pages 903-925.
    9. Agyepong, Irene Akua & Nagai, Richard A., 2011. ""We charge them; otherwise we cannot run the hospital" front line workers, clients and health financing policy implementation gaps in Ghana," Health Policy, Elsevier, vol. 99(3), pages 226-233, March.
    10. Magnus Lindelow, 2003. "The Utilization of Curative Health Care in Mozambique: Does Income Matter?," Economics Series Working Papers WPS/2004-11, University of Oxford, Department of Economics.
    11. Onwujekwe, Obinna & Uzochukwu, Benjamin, 2005. "Socio-economic and geographic differentials in costs and payment strategies for primary healthcare services in Southeast Nigeria," Health Policy, Elsevier, vol. 71(3), pages 383-397, March.
    12. Mataria, Awad & Donaldson, Cam & Luchini, Stephane & Moatti, Jean-Paul, 2004. "A stated preference approach to assessing health care-quality improvements in Palestine: from theoretical validity to policy implications," Journal of Health Economics, Elsevier, vol. 23(6), pages 1285-1311, November.
    13. Valeria Oliveira-Cruz & Kara Hanson & Anne Mills, 2003. "Approaches to overcoming constraints to effective health service delivery: a review of the evidence," Journal of International Development, John Wiley & Sons, Ltd., vol. 15(1), pages 41-65.
    14. Awad Mataria & Stéphane Luchini & Yousef Daoud & Jean-Paul Moatti, 2007. "Demand assessment and price-elasticity estimation of quality-improved primary health care in palestine: a contribution from the contingent valuation method," Health Economics, John Wiley & Sons, Ltd., vol. 16(10), pages 1051-1068.
    15. Xu, Ke & Evans, David B. & Kadama, Patrick & Nabyonga, Juliet & Ogwal, Peter Ogwang & Nabukhonzo, Pamela & Aguilar, Ana Mylena, 2006. "Understanding the impact of eliminating user fees: Utilization and catastrophic health expenditures in Uganda," Social Science & Medicine, Elsevier, vol. 62(4), pages 866-876, February.
    16. Mataria, Awad & Giacaman, Rita & Khatib, Rana & Moatti, Jean-Paul, 2006. "Impoverishment and patients' "willingness" and "ability" to pay for improving the quality of health care in Palestine: An assessment using the contingent valuation method," Health Policy, Elsevier, vol. 75(3), pages 312-328, February.
    17. Cleary, Susan & Birch, Steve & Chimbindi, Natsayi & Silal, Sheetal & McIntyre, Di, 2013. "Investigating the affordability of key health services in South Africa," Social Science & Medicine, Elsevier, vol. 80(C), pages 37-46.
    18. Poletti, Tim & Balabanova, Dina & Ghazaryan, Olga & Kocharyan, Hasmik & Hakobyan, Margarita & Arakelyan, Karen & Normand, Charles, 2007. "The desirability and feasibility of scaling up community health insurance in low-income settings--Lessons from Armenia," Social Science & Medicine, Elsevier, vol. 64(3), pages 509-520, February.
    19. Leighton, Charlotte, 1996. "Strategies for Achieving Health Financing Reform in Africa," World Development, Elsevier, vol. 24(9), pages 1511-1525, September.

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