Inequity in the Bamako Initiative programme--implications for the treatment of malaria in south-east Nigeria

An exploratory study was carried out to examine the utilization of malaria treatment services in the Bamako Initiative (BI), the exemption practices and the cost recovery of user-fees for treatment of malaria in south-east Nigeria. Structured questionnaires were used from 1594 households to collect socio-economic and demographic information, the utilization of health care services and experience with user fee exemption. Historical data on malaria utilization rates from 1991 to 2000 were obtained from health centres. In addition, financial information was collected on the annual BI revenue. Health centres for malaria experienced a drop in outpatient attendance when the programme started which later rose again. The more affluent population, as assessed by household belongings and education, used the health centres more often than the poorer population, were more aware of exemptions and benefited from exemptions more than the poorer and lesser educated populations. The sale of anti-malaria drugs was a large proportion of the costs recovered. BI appears to have increased malaria care utilization but has also raised some equity issues. It seems that richer households benefited more than poorer households.     

Implementation of the Bamako Initiative: strategies in Benin and Guinea

Two West African countries, Benin and Guinea, have been reorganizing their peripheral health systems since 1986, with the goal of improving access to primary health care (PHC). A comprehensive approach evolve, based on improving effectiveness, optimizing efficiency, ensuring financial variability and promoting equity. These strategies were launched as the Bamako Initiative by the World Health Organization's Regional Assembly in 1987. This is the first in a series of five articles on the Bamako Initiative in Benin and Guinea. The strategies implemented in these two countries are discussed. Subsequent articles discuss the improved health indicators, impact on service costs efficiency, and community empowerment through local cost recovery and equity implications. The health center is the basis for a revitalized primary care system. From here, an integrated minimum health care package is readily accessible to meet basic community health needs. Through the Bamako Initiative program, drugs and other essential resources are always available, regular contract between the community health service providers and communities has increased, and the quality of care has improved while also becoming more efficient. Community health resources are managed locally through joint microplanning and monitoring, involving health personnel and village committees. Community ownership, fostered by local budgeting and decision making, is an essential pillar for the success of the system.     

Twelve years after the Bamako initiative: facts and political implications for equity in health services accessibility for indigent Africans

Launched in 1988, the Bamako Initiative was considered as a policy aimed at revitalizing the primary health care strategy while strengthening equity in access to health care. A decade later, two research initiatives conducted in Mali and Uganda, and later in Burkina Faso, concluded that a) this policy did very little to improve or increase access to health care among the most deprived and excluded vulnerable population groups, b) this policy only served to marginalize certain population groups already disenfranchised due to the emphasis on financial sustainability and viability of health care organisations, and c) the exemption mechanisms for alleviating the burden of payment and financial barriers for the poorest represent a technically feasible solution, while one not socially advocated. The current state of affairs requires that in order to give impetus to the principles of equity and the initial goals of the Bamako Initiative, African states should implement incentives, NGOs should consider planning as a tool for social change and donors need to ensure investments which are centred upon and prioritize principles of equity.     

The Kenyan model of the bamako initiative: Potential and limitations

Kenya has developed a model of the Bamako Initiative which differs in some respects to that developed in other African countries. It has established a system of community pharmacies in peripheral areas which acts as the locus of a community financing programme, focused on the provision of drugs and disease control activities carried out by Community Health Workers. This model addresses problems of geographical accessibility rather than quality in existing services. While it responds to the most urgent health service problems in Kenya, it ignores the communities felt needs for the extension of services to treat serious illnesses. Nevertheless, the Initiative has been successful in generating community enthusiasm and in establishing an affordable and sustainable services. It is important that the Bamako Initiative is not marginalized from the ‘main’ health service delivery system and is not seen as a substitute for extension of services. In the longer term, the Initiative should be used to support efforts to strengthen quality and improve accessibility at higher levels.     

Preventive activities in primary health care in Stockholm County, Sweden. Results from a survey in November 1985

A survey was conducted, during November 1985, in 110 Stockholm Public Primary Health Care Centres (PHCC) to study ongoing preventive activities. In 71% of the Health Centres there was an awareness of special risk groups in the PHCC area, such as alcohol abusers, elderly people and single parents, and in 40% of more specific risk factors like unemployment and loneliness. Individualised preventive activities were provided in 25% and group oriented activities in 50% of the health centres. There were great differences between the different regions of Stockholm County and, for example, quit-smoking groups were not distributed according to the geographical needs, i.e. to the areas with the highest prevalence of smokers. Involvement of PHC in community-based preventive activities is still rare but has started in the area of accident prevention in some PHCC. The study also underlines the need for more education as well as support to increase the element of prevention in primary health care activities.     

Canadian community health centres and the Internet: exploring the challenges and solutions

Community Health Centres (CHCs) across Canada are providing essential health and social services to many communities, and this function is becoming more vital as provinces concentrate on cutting costs and developing more economic and efficient solutions to the current healthcare system. More than 300 of these community-based organizations currently serve upwards to 13% of the Canadian population, providing a wide range of services in an attempt to promote total wellness in their communities. Over one half of all CHCs are located in rural or remote areas. However, despite the apparent need for, and success of, CHCs, they are among the most underserved health provision groups in the country. Many CHCs lack critical funding and resources, particularly in the area of technology. In this Information Age, the health sector is realizing the importance of using information technologies to increase efficiency, improve services, and maintain viability. Community Health Centres, however, often do not have money for even the most basic technologies such as fax machines, let alone computers and Internet access. Community Health Centres in Canada need to be given the tools they need in order to continue providing quality health care to their communities. This article provides an overview of the current situation of CHCs in Canada vis(-)à-vis the Internet and other information technologies. Some of the practical and organizational challenges facing CHCs in this area will be discussed, as well as potential solutions that could and are being developed to overcome these barriers. It is an objective of this article to facilitate information and resource-sharing and the creation of links between CHCs across Canada. Community Health Centres may benefit from better understanding of the implications of these new technologies, discovering ways in which their peers are using the Internet, and communicating with one another in order to begin basic planning and needs assessments. As part of this overview, a brief update on the status of the HealthNet Community Access Pilot will be provided. The HealthNet Community Access Pilot is a collaborative project aimed at educating and providing CHCs across Canada with the tools to help them begin implementing Internet systems and policies within their own context. Part of this grassroots effort involves developing appropriate technical solutions, software, training materials, and support resources to help demystify and simplify the technology. Some of these tools and recommendations will be available at ITCH '96 for use by other CHCs.     

The network of WHO Collaborating Centres in Occupational Health and the role of maritime centres

The WHO Network of Collaborating Centres in Occupational Health comprises 70 Collaborating Centres. Four of these Centres are specialised in Maritime Occupational Health and they are situated in Poland, Germany, Denmark and the Ukraine. All Collaborating Centres follow the mandate of the Occupational Health Programme in WHO, which is the Global Strategy on Occupational Health for All. Collaborating Centres in Maritime Occupational Health cover a specific group of workers who are exposed to different work environments than workers on land. They are often not at all or only insufficiently covered by any health services. The Collaborating Centres in Maritime Occupational Health provide an excellent example of international collaboration.     

Costs and financing of improvements in the quality of maternal health services through the Bamako Initiative in Nigeria

This paper reports on a study to assess the quality of maternal health care in public health facilities in Nigeria and to identify the resource implications of making the necessary quality improvements. Drawing upon unifying themes from quality assurance, basic microeconomics and the Bamako Initiative, locally defined norms were used to estimate resource requirements for improving the quality of maternal health care. Wide gaps existed between what is required (the norm) and what was available in terms of fixed and variable resources required for the delivery of maternal health services in public facilities implementing the Bamako Initiative in the Local Government Areas studied. Given such constraints, it was highly unlikely that technically acceptable standards of care could be met without additional resource inputs to meet the norm. This is part of the cost of doing business and merits serious policy dialogue. Revenue generation from health services was poor and appeared to be more related to inadequate supply of essential drugs and consumables than to the use of uneconomic fee scales. It is likely that user fees will be necessary to supplement scarce government budgets, especially to fund the most critical variable inputs associated with quality improvements. However, any user fee system, especially one that raises fees to patients, will have to be accompanied by immediate and visible quality improvements. Without such quality improvements, cost recovery will result in even lower utilization and attempts to generate new revenues are unlikely to succeed.     

Socio-economic differences and health seeking behaviour for the diagnosis and treatment of malaria: a case study of four local government areas operating the Bamako initiative programme in south-east Nigeria

Background  

Malaria is one of the leading causes of mortality and morbidity in Nigeria. It is not known how user fees introduced under the Bamako Initiative (BI) system affect healthcare seeking among different socio-economic groups in Nigeria for diagnosis and treatment of malaria. Reliable information is needed to initiate new policy thrusts to protect the poor from the adverse effect of user fees.     

Financing health care at the local level: the community drug funds of Honduras

In response to UNICEF's Bamako Initiative, hundreds of privately run Community Drug Funds were established in Honduras during the 1990s, generally under the auspices of a non-government organization and usually with the financial assistance of international agencies. Honduras' Community Drug Funds (CDF) are rotating drug funds intended to: (1) serve as a means of increasing access to care in isolated rural populations, (2) promote the more rational use of medicines and (3) promote community participation in the financing and oversight of primary health care activities. This study is the first to analyse empirically the impact and efficiency of these institutions, relying upon primary data obtained from a survey of 51 of the 450 active CDFs in Honduras. Archival data from Ministry of Health and other sources were also analysed. The structure, operations, and impact of CDFs are detailed, with special attention given to access and quality of care issues. The study found that CDFs are rapidly becoming under-capitalized because of basic management problems, principally in pricing and in medicine purchasing practices. These shortcomings, and more generally, increasing financial pressures on NGO sponsors, are negatively affecting quality and access to care. Given the rate of erosion in CDF assets, unless they are recapitalized, the current average estimated lifespan of a CDF is 5.5 years. If these funds are to be sustainable, changes in their financing, training and supervision will be required. In addressing these issues, Honduran health policy-makers must decide how best to balance the competing goals of holding down costs, while maintaining adequate quality and improving access to care.     

Developments in the new genetics

The advent of recombinant DNA has introduced novel ways of diagnosing genetic disorders. The application of these techniques in affected families, coupled with genetic counselling, should help prevent the recurrence of a proportion of cases, and thereby reduce a considerable amount of suffering, and in some cases the expense of caring for a severely affected individual. However, such aims may be achieved only when the importance of such services is more widely recognized and they become more generally available. Counselling and prenatal diagnostic services have been available in University Centres of Medical Genetics for at least the last 20 years yet still only a proportion of the population at risk avail themselves of these services. The role of Health Departments in ensuring that those at risk are aware of and then use these facilities is clear. Health education must play an important role in this regard. Furthermore, there is a real need for financial support to employ adequately trained medical and technical staff in such centres. Currently, these problems are being debated by such bodies as the Clinical Genetics Society and the Royal College of Physicians. With the co-operation, help and support of Public Health Departments in the future, these exciting developments will not remain within the confines of research laboratories but will be extended to the community at large. In this way all those at risk in the population can benefit.     

Health literacy within the reality of immigrants' culture and language

The Second Canadian Conference on Literacy and Health addressed issues of health literacy, culture, and linguistic diversity. This article aims to introduce the presenters' ideas, reports of the learners' discussion, and attendees' recommendations. There is also a literature review of the links between health literacy and use of health services among newcomers in Canada. Newcomers to Canada tend to be unfamiliar with the Canadian health care system in terms of navigating needed services and/or seeking health-related information. Health professionals report difficulties in communicating effectively with these populations about risk-taking behaviours. Educational resources and approaches only partially reach people from cultural minorities. E-health information does little for those with language and literacy limitations. Barriers to accessing information, specifically written material, are widely reported. Consequently, many ethnocultural groups do not participate in health promotion initiatives. Among newcomers to Canada, the problems of adapting to a new health culture are linked to both a lack of information about the new health care available and subsequently their experience with that health care system. There is also a structural barrier. It includes lack of access to preventive health care services and the lack of a formal and informal support network. This results in less effective use of these preventive services. Linguistic, religious, and cultural factors contribute to the newcomers' social isolation. Multidisciplinary work to enhance health literacy and awareness about health and healthy lifestyles will permit ethnocultural populations to develop their potential and more fully enjoy their lives in Canada. Simultaneously, health educators should have the opportunity to realize their limitations and challenges in dealing with the complexity of providing health education to this population. There remain gaps in our knowledge about the access and use of health services by subpopulations from different cultural groups in terms of their gender, learning practices, ways of navigating services, and help-seeking behaviours.     

Comparative anthropometrics of 3 to 24-month-old children breastfed in both high and low socio-economic strata in Lagos, Nigeria

This is a cross-sectional study of infants seen in the Nitel Health Centres in Lagos metropolis and Mushin Primary Health Care Centres in the Mushin Local Government Area of Lagos State. A total of 297 infants aged 3-24 months were studied. Anthropometric and breast feeding patterns of the children were studied. The mean weights of the mothers were 67.2 kg for Nitel mothers and 62.11 kg for the mothers in Mushin Primary Health Care Centres. The mean heights for the mothers were 71.47 cm and 66.1 cm, respectively. About 98.8% of the mothers in the Primary Health Care Centres of Mushin breastfed. About 7.4% of the total population studied had WAZ scores of less than -2s.d. while 12.8% had HAZ scores of less than -2s.d. and 7.43% had WHZ scores of less than -2s.d. Malnutrition was considered to be very high. There was a positive correlation between the anthropometric measurement and education.     

Health insurance coverage and the use of preventive services by Mexican adults

The lack of health insurance coverage could be a potentially important deterrent to the use of preventive health care by older adults with high rates of chronic co-morbidities. We use survey data from 12 100 Mexican adults ages 50 and older who participated in the 2001 Mexican Health and Aging Study (MHAS) to analyze the relation between health insurance coverage and the use of preventive health-care services in Mexico. Uninsured adults were less likely to use preventive screenings for hypertension, high cholesterol, diabetes and (breast, cervical and prostate) cancer than insured adults. After adjusting for other factors affecting preventive care utilization in a logistic regression model, we found that these results still hold for high cholesterol and diabetes screening. Similar results hold for the population not working during the survey week and for adults earning below 200% of the poverty line. Our results suggest that insured adults are in a relatively better position to detect some chronic diseases - and have them treated promptly - than uninsured adults because they have better access to cost-effective preventive screenings. Recent public policy initiatives to increase health insurance coverage rates in Mexico could lead to substantially higher preventive health-care utilization rates and improvements in population health.     

Local cost sharing in Bamako Initiative systems in Benin and Guinea: assuring the financial viability of primary health care

The fourth in a series of five, this article presents and analyses data on cost recovery and community cost-sharing, two key aspects of the Bamako Initiative which have been implemented in Benin and Guinea since 1986. The data come from approximately 400 health centres and result from the six-monthly monitoring sessions conducted from 1989 to 1993. Community involvement in the financing of local operating costs in the two national scale programmes is also described. In Benin and Guinea, a user fee system generates the community financed revenue with the aim of covering local operating costs including drugs. Health worker salaries remain the responsibility of the government and donor funding covers vaccine and investment costs. Village health committees manage and control resources and revenue. The community is also involved in decision making, strategy definition and quality control. In Benin in 1993, community financing revenue amounted to about US$0.6 per capita per year and generally covered all local recurrent non salary costs except vaccines and left a surplus. Although total costs and revenues were slightly lower in Guinea for the same period, over-all user fee revenue (around US$0.3 per capita per year) covered local recurrent costs (not including salaries or vaccines). A comparison of costs and revenue between regions and individual health centres revealed important differences in cost recovery ratios. In Benin, some centres recovered more than twice the local costs targeted for community financing. Twenty-five per cent of centres in Guinea did not manage to cover their designated local recurrent costs. The longitudinal analysis showed that the level of cost recovery remained stable over time even as preventive care (and especially EPI) coverage rose significantly. To better understand the most important characteristics affecting cost recovery levels, best performing health centres in terms of cost-recovery levels in 1993 were compared to worst performing centres. This analysis showed that the size of the target population of the health centre is a key determinant of cost-recovery in both countries. In addition, in Guinea the utilization of curative care linked to geographical access and in Benin the average revenue per case linked to the number of deliveries proved to be additional factors of importance. In best performing centres, financial viability improved over time in both countries between 1990 and 1993. Finally, the implications of these conclusions for the planning of health centre revitalization in West Africa are discussed.     

National community health insurance at village level: the case from Guinea Bissau

The experience in Guinea Bissau of a voluntary levy scheme atvillage level, called ‘Abota’, makes one point veryclear. Collective health insurance schemes at village levelmay be feasible and manageable in rural parts of Africa if thevillage population is allowed to decide on the amount of moneyand method of collection and if the government supports thescheme by guaranteeing sufficient drugs, low prices, effectivecontrol measures and a village health worker who is officialllypart of the national referral system. Without these conditions, cost-recovery schemes should perhapsbe postponed until a continuous and integrated care system canbe guaranteed. It should be recognized that the absence of aninformal drug market in Guinea Bissau and the relative isolationand small-scaleness of its population have been two importantenabling factors for the success of the collective health insurancescheme. Suggestions to introduce similar cost-recovery schemesin other settings therefore need to be analysed with caution.The best that UNICEF and WHO can do at the moment, related tothe Bamako Initiative, is to abandon the ‘easy and rapidsolutions approach’ to development and negotiate withnational governments for a more equitable and participativeapproach to improve the health of those that both UN agencieswant to serve. Fee-for-service schemes appear the easiest solutionto cost recovery, but they are not necessarily the best in thelong-term.     

Developing knowledge translation capacity in public health: the role of the National Collaborating Centres

This paper outlines the history and rationale of the six National Collaborating Centres for Public Health program, established by the Public Health Agency of Canada in 2004. The Centres are not focused on primary research, but rather on synthesizing the global scientific evidence relevant to public health policies, programs and practices--and its translation into useful "knowledge products" for public health professionals, policy-makers and community groups to inform public health decision-making. The broad principles of knowledge synthesis and translation/exchange (KSTE) for public health applications are reviewed, as are recent publications and websites describing international projects in this burgeoning field. Finally, some best practices for public-health-oriented KSTE derived from experiences in Canada and elsewhere are described.