E-drug: Bamako Initiative (cont'd)
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I have been very sceptical of the conceptual underpinnings of the
Bamako Initiative. At the time the BI was promoted there was a very
good editorial in Lancet and an article in Health Policy and Planning
that challenged the basic concept of the Initiative.
As often happens the BI has come to mean different things to
different people. As originally proposed it was intended to be a
community managed revolving drug fund that would charge 200 -
300% markups to generate extra revenue to pay for primary care
activities. This never worked and it quickly evolved into a cost
recovery program for rural health facilities. In some countries where
there was nothing else particularly the Francophone west African
countries after the CFA devaluation versions of the scheme persisted.
My problem with the approach is that I would argue that the last
people who should be charged are the poor rural dwellers of the
country. Before you start charging these people, the hospitals and the
urban OHC facilities should recover costs effectively. If you have free
urban or hospital care with charging for rural services, you encourage
by-passing. With regard to administrative efficiency the rural facilities
are least likely to have staff or facilities (eg banks) to manage a
revolving fund. With regard to quality of care staff are under a
perverse incentive to prescribe more to increase income for the
facility. The scheme did not address the problems caused by currency
fluctuations or inflation.
I have read the articles published by UNICEF and in the International
Journal of Health Services Management and am very unimpressed
with the quality of the data presented. I hope that this new
conference can share some well collected data on issues such as
quality of care, access, drug prices and administrative indicators of
efficiency.
The work reported by Kathy Holloway is very different. This is a cost
recovery scheme managed by an NGO (BNMT) with a substantial
subsidy, high level technical support and with an orientation to equity
in access and improving the quality of care in these facilities.
I hope that the papers presented at the conference can be made
widely available.
Richard Laing Tel 617 414-1444
Associate Professor Fax 617 638-4476
Department of International Health E-mail richardl@bu.edu
Boston University School of Public Health
715 Albany St
Boston MA 02118-2526, USA
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