Foreword
Dr. Takusei Umenai
The concept underlying the Bamako Initiative of user contributions and community co-management of health care services has been found acceptable in many countries, even though the Initiative was started to address weak and often inappropriate health services, including the acute and prolonged shortage of drugs in countries of Sub-Saharan Africa. In practice, however, the application and operationalization of the assumptions of the Bamako Initiative through a variety of programmatic approaches has had mixed results in these countries. A review of the Bamako Initiative in the Sub-Saharan region, conducted in 1993 by UNICEF, has confirmed these mixed results.
Two years ago, The Nippon Foundation (then known as the Sasakawa Foundation) made the decision to support the formation and operation of revolving drug funds (RDFs) to address the increasing shortage of drugs in many Asian countries that were moving away from government-sponsored, free comprehensive health care policies to the incorporation of user contribution. At that time, it was recognized that the Asian countries were different from the Sub-Saharan African countries in the following ways:
1. While GNP per capita figures in the Asian countries were not too different from those of some of the Sub-Saharan African countries, economic infrastructures in Asia were not primarily based on exports of commodities; there were other economic activities other than primary production and rather different economic orientations.
2. In Asia, there were relatively high literacy rates among men and women, especially in those countries emerging from socialist pasts. This contributed to the availability of trained manpower which geographically was reasonably well distributed.
3. Many of the countries selected for support had relatively better organized systems of government than Sub-Saharan countries, especially at the district and sub-district levels.
4. In Asia, the entrepreneurial spirit of the people, especially at the community level, appeared to be quite vibrant, particularly in countries moving towards market economies. The successes of the so-called “Asian Tigers” seemed to have a stimulative effect on their neighbors.
Equity is repeatedly emphasized whenever there is discussion of delivery of health services and in the setting-up of projects. The concept of user contributions has been challenged as not contributing to equity as the poor often end up paying the user charges while those who can afford to pay end up not paying anything for a variety of reasons. There are apparently two perceptions of equity. One perspective appears to assume that the individual has the right to make the choice of whatever health services he or she wishes to make, provided that he/she has the resources to pay for these services. The other perspective, however, maintains that the basic range of services is collectively determined (usually by representatives) and is not based on the clamoring of a very articulate minority. The former places profit as the primary motive and the latter, service. Both perspectives recognize the value of fairness in terms of access and affordability and place emphasis on a high quality of care. Both consider health services as merit goods endorsed by society, and require that these be provide as a social service should the individual be unable to bear the costs personally. Therefore, the challenge of equity in health care, in economic terms reinforced by increasing access to information about the range and quality of services available elsewhere, is that the resources required for all to enjoy benefits currently available to a privileged few hold for ransom the planetary legacy of future generations. Thus, common ground needs to be found for the two perspectives so that an operational framework can be developed which ensures that equity holds a central place in the provision of health care services.
Supporting RDFs in the selected countries is regarded by The Nippon Foundation as a move which supports the ensurance of equity in terms of access and affordability. By limiting the availability of seed stock as capital for a definite period, a creative tension is generated in health services and within communities, which works to sustain these RDFs and contribute to the improvement of publicly provided health care services.
This interim review of the projects supported by The Nippon Foundation was a first step in a process to assess the impact of RDFs. It looked at RDF performance, at the functioning of replenishment systems, at community participation in the operation and co-management of RDFs, and at the strengthened management capacity of health teams to ultimately improve and increase the relevance of primary health care services provided by the government.
