The Bamako Initiative: where is it going

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Abstract
The Bamako Initiative was launched in September 1987 as a means of increasing access to essential drugs through community participation in revolving drug funds. The response of the public health community was highly critical of the Initiative. Issues raised included equity and access; problems of integration, management and logistics; the relative importance given to drugs; and sustainability and dependency. The Initiative has evolved in part in response to these criticisms, now focusing on increased accessibility and quality of services, and the strengthening of health system management. An evaluation carried out in 1991 reviewed the main areas of criticism. In all areas, a relative approach was found to be useful. For example, while substantial problems of equity and affordability exist, in some cases, services of a given quality have been made available more cheaply than before. The most important outstanding policy issues were considered to be: the need to strengthen community support mechanisms for those without economic access to services and to develop payment mechanisms compatible with seasonal income patterns; the feasibility of regional cross-subsidization of revenues; the development of an improved model of community participation; and the nature and extent of external support to the programme.

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