As Mali Scraps Healthcare Fees, It Is Time to Bury The Bamako Initiative

The end of the controversial Bamako Initiative, which paved the way for charging the poor to access health care, could finally be in sight as its birthplace Mali joins the growing number of African countries scrapping user fees in moving towards universal health coverage (UHC).

Expert comment Published 15 March 2019 Updated 25 March 2019 2 minute READ
Health care in Timbuktu, Bellafrandi, northern Mali. Photo by COLIN DELFOSSE/AFP/Getty Images.

Health care in Timbuktu, Bellafrandi, northern Mali. Photo by COLIN DELFOSSE/AFP/Getty Images.

The announcement by Mali to abolish healthcare user fees for children under five, pregnant women and elderly people over 70 is not the first time an African leader has taken this initiative. But the impact of President Keïta’s announcement extends beyond the national borders – because Mali, and in particular its capital, Bamako, had a major historic role in formalizing and encouraging the charging of healthcare user fees in the first place.

The World Bank first promoted the idea that African countries should charge user fees for health services back in the mid-1980s – an era of structural adjustment programmes, which required countries to cut public spending as a condition for receiving World Bank loans and shift the burden of financing social services to households.

Despite protests and warnings of poor households not being able to access vital services, this policy was soon imposed across practically the whole of sub-Saharan Africa. But it was in Mali that a compromise was agreed on the charging of user fees, which perhaps had the biggest impact in ensuring it became standard practice across Africa. Called the Bamako Initiative, it argued that charging user fees could actually benefit the poor.

Laudable intentions failed miserably

The theory went that, if the local community had a role in setting fee rates and managing revolving drug funds (by patients being charged slightly above the wholesale price to maintain drug stocks) services would be affordable and quality maintained. Also, the community could decide who would be exempted from these payments and benefit from free care.

Despite laudable intentions, it is clear the Bamako Initiative failed miserably – especially in its primary objective of helping poor families access health care. Evidence from low-income West African countries typically show people, on average, use curative health services once every three years whereas in OECD countries it is around seven visits per year.

Faced with underfunded services, high user fees, and non-functioning exemption mechanisms, poor families effectively stopped using public health facilities. Perhaps it was not surprising that an Ebola outbreak in 2014 became an epidemic in a region where populations had largely abandoned their public health systems.

But despite the failings (and evidence of huge increases in health service use from countries that had scrapped fees), Bamako Initiative proponents, notably UNICEF, continued to champion its merits. As recently as 2008, in its State of the World’s Children Report, UNICEF celebrated the Bamako Initiative, highlighting its apparent success in three West African countries – despite all of them registering some of the highest child mortality rates in the world. One of these countries was Mali – birthplace of the initiative.

Since then, however, there has been a radical shift in global health financing policies. In 2010, WHO published a World Health Report recommending countries replace “out-of-pocket health financing” (user fees) with higher levels of public financing, with a view to achieving Universal Health Coverage (UHC). Now UHC is driving the global health agenda, with WHO and the World Bank assessing progress towards this goal by measuring how quickly countries reduce catastrophic health spending caused by user fees.

In effect, countries are being ranked on how successfully they abandon the World Bank’s policy directives of the 1980s. And the rankings do show that some regions are moving faster towards publicly financed UHC than others – Europe, East Asia, Australasia and the Americas (with the glaring exception of the United States) perform better than South Asia and sub-Saharan Africa.

But it is West Africa that has fallen behind the most and where a Chatham House paper showed that thousands of people are being detained in hospitals because they can’t pay their hospital bills.

Taking money from the poor and sick

Might this region’s poor performance be related to the fact that it was here that ideology of expecting people to pay directly for their health services became so entrenched through the Bamako Initiative? Certainly President Keita’s announcement is a clear rejection of the concept that taking money from poor people when they are sick is a good idea.

Presidents in Uganda, Zambia, Liberia, Uganda, Burundi and Sierra Leone have all also made similar policy changes in recent years, and in each case there have been large increases in the uptake of essential health services by women and children, which augurs well for the policy change in Mali.

Even at the time of its launch, one of the biggest critics of the Bamako Initiative was Jim Yong Kim – later to become president of the World Bank itself – who highlighted the dire consequences of the policy in his book “Dying for Growth”.

What has become abundantly clear is that, for the sake of the millions of people still excluded from health care in the region because of user fees, it is high time the World Bank, UNICEF and WHO finally bury the Bamako Initiative.