The Bamako Initiative
Bamako, Mali, 8 March 1999
Your Excellency, Mr. President; Your Excellency, Mr. Prime Minister; Your Excellency, Madame Minister of Health, Aged People and Solidarity; the Regional Director of WHO; Your Excellencies, the Ministers; Your Excellencies, members of the diplomatic corps and representatives of international agencies; honourable guests:
It is with enormous pleasure that I have accepted on behalf of UNICEF the invitation made by the Government of Mali to speak to this illustrious gathering.
Mr. President, development is, by definition, a long-term undertaking. And by that measure, the nearly 12 years that have passed since the Bamako Initiative was first embraced by African Health Ministers have been equivalent to the blink of an eye. Yet the split-second of development history that began in 1987 has already made a profound difference to the lives of millions of children and women – not only here in Africa, but around the world. And it continues to make a difference to this day.
Thanks to the process that was launched in Bamako with the World Health Organization (WHO) and UNICEF, the world has seen significant reductions in maternal and child mortality – reductions that have brought us closer to our goal of assuring every child a better future.
Mr. President, the Bamako Initiative is a testament to the hard work and solidarity of untold numbers of dedicated people on the ground – many of you here, at this important conference – who understood from the very beginning that the key to accessible and affordable health care for all lies in the informed involvement of local communities.
Indeed, since the Initiative was adopted, we have seen abundant evidence that communities possess not only the motivation, but the capacity, to participate in the management of their own health care services.
Thanks to the Bamako Initiative, improved and sustained immunisation coverage and other preventive activities have grown as governments have increased their capacity to provide essential drugs and vaccines.
Even in countries facing severe economic distress, the Bamako Initiative has ensured that revitalised basic health care facilities have been able to offer a variety of services, including provision of essential drugs.
The recently introduced Health Sector Reforms – which in some countries were preceded by the Bamako Initiative – have sought to accelerate the move toward more equitable access to quality health care and a more efficient use of resources.
These efforts have not only improved the well-being of whole populations – they have empowered individuals and families to assume responsibility for their own health and welfare. And it is in that sense, Mr. President, that the Bamako Initiative has been a major step toward democratising the business of primary health care.
The success of the Bamako Initiative can be traced directly to three major factors: the willingness of leaders at all levels of the health sector to be innovative, to take risks, and to be effective communicators; the solid technical excellence that can be found even in small-scale projects – and the flexibility of the Initiative itself, which, instead of fixed, top-down measures, offers a set of strategies for revitalising health services that can be adapted to a wide variety of situations and cultural contexts.
All told, some 35 countries have implemented the eight basic principles of the Bamako Initiative for use in nationwide programmes – programmes that involve such major components as immunisation, vitamin A supplementation, safe motherhood, guinea-worm eradication and community participation activities.
In Africa alone, the Bamako Initiative has helped ensure access to affordable and sustainable primary health services for more than 60 million people through the revitalisation of 6,000 health centres – managed and partially funded by local communities or districts in countries like Cameroon, the Gambia, Mali, Mauritania, Niger, Nigeria, and Togo.
In West Africa, some 30 per cent of all health centres in 15 nations have been revitalised. Indeed, some countries, like Benin, Guinea and Senegal, have succeeded in strengthening virtually all of their public primary health centres with additional help from the World Bank and bilateral partners.
But as we approach the millennium, Mr. President, enormous challenges remain.
A decade of gains in child survival are being reversed by the terrible effects of the HIV/AIDS pandemic, combined with the continuing scourges of malaria and malnutrition and micronutrient deficiencies, among others.
At the same time, deteriorating economic conditions and civil strife in many countries have disrupted long-term planning and provision of health services.
Furthermore, accessibility to basic health services remains a major problem in sub-Saharan Africa and parts of Asia. In numerous places, the majority of people still live more than five kilometers away from the nearest health center.
Quality of care has also lagged behind the increase in coverage, often contributing to the under-utilization of services and slowing efforts to reach the health and nutrition goals of the World Summit for Children.
Because of the Bamako Initiative, we know that the decentralization of government to a sub-national level can help promote intersectoral health interventions while empowering communities. But there is a potential downside: decentralisation can also complicate the implementation of a coherent national health policy because of conflicting local interests.
Preventive care also tends to suffer because curative and hospital-based care is more visible and often reaps more financial and political benefits. Decentralisation must be accompanied by measures to ensure that the technical and logistical support previously provided by traditional “vertical programmes” is made available to health teams in the decentralised entities.
Mr. President, this review of the implementation of the Bamako Initiative is a moment to take stock of how far we have come – and to assess what steps we must take to build on past achievements. Let me suggest a few:
We must ensure that the decentralisation of responsibility for health care management is matched by enhanced resource allocation and decision-making at local levels.
Sector Wide Approaches, which have been promoted in several of the countries implementing the Bamako Initiative, could bring about more consistent government leadership, improved donor coordination and more efficient use of resources, including at decentralised levels.
However, since these approaches involve such a wide range of sectoral issues, we must guard against a tendency to increase administrative burdens in programme planning and implementation – causing a corresponding decrease in the involvement of communities and the civil society. There is also a risk that intersectoral collaboration for solving health problems will decline, depriving programmes of flexibility and capacity to innovate.
Mr. President, these are all daunting problems – and the strategies and recommendations that emerge from this conference must address them if we are to ensure the protection of children’s rights, help meet their basic needs – and expand their opportunities to fully develop and participate.
You must draw on past lessons, but do so within the context of rapidly changing global and local conditions and declining financial and human resources – including the continuing plunge in Official Development Assistance, a situation that has put the lives of millions of children and women at risk.
Excellencies, Distinguished Delegates: Over the next five days, I would challenge you to include some of the following topics in your discussions:
First, we must assure the right of all children and women to good quality essential health care. This implies adapting existing strategies to ensure that the most marginalised and difficult-to-reach populations have access to quality health care. Specific strategies may include additional outreach capacity, use of national child days, strengthening of referral care and alliances. Specific strategies will need to differ – some must address the needs of scattered populations or the urban poor, while others, such as in Asia, must be designed to take account of the enormous number of beneficiaries who must be reached. Health sector reforms represent a new opportunity to advocate for the responsibility of governments to assure access for all to the basic package of essential care, regardless of who actually provides that package.
Second, we must strengthen and broaden partnerships for health. To assure universal coverage with a minimum package, other service providers should be included from the start: the private sector, non-governmental organisations (NGOs) and schools, for example – and partnerships must be promoted between them and communities at the local, district and national levels. Civil society, especially through women's and youth groups, must also be involved as co-actors, and in governance at the local level. The expansion of partnerships must also take into account the cost of services and local capacity to pay. We cannot expect the world’s poorest citizens to be wholly responsible for health care that, in more fortunate areas of the world, is covered by insurance, subsidies and grants. We must find creative avenues to ensure that all partners, including governments and the international community, make good on their obligations to guarantee the right to health services for all.
Third, the minimum package of health activities must be adapted to include strategies to control new and re-emerging problems and take advantage of recent technological advances, using the opportunity of global initiatives and approaches. This includes prevention of mother-to-child transmission of HIV as well as sexually transmitted diseases (STDs); the Roll Back Malaria effort; the eradication of polio; better control of vaccine-preventable diseases, and the Integrated Management of Childhood Illness (IMCI), as well as maternal and neonatal mortality reduction and adolescent health.
Finally, more emphasis must be placed on empowering women and young people to promote their own well-being and to acquire basic life-skills. This can be achieved by strengthening self-care practices and household care of children. In this way, women and young people can play a more effective role in improving their own health and the health of their community.
Mr. President, let me remark, in closing, on a particularly pleasing piece of historical symmetry: the fact that this meeting has convened on the same day that the world is observing the last International Women’s Day of the 20th Century.
It is therefore a doubly appropriate occasion to reflect on the progress made in the struggle for equal rights for women, and on the need to ensure their full participation in the development process.
Women have been key to the success of the Bamako Initiative to date, both as beneficiaries and as contributors to health initiatives.
Yet as the Secretary-General points out in his Women’s Day message, “gender equality, to which we have so long aspired, is still far from reality.” And as a result, women and girls continue to pay with their lives for inadequate provision of health care.
Mr. President, it is clear that one of the key challenges to effective health care remains the full participation of women. In many countries, they are still marginal actors in health care delivery, both in numbers – and especially in decision-making.
Even in their own households, women often lack the power to make decisions relevant to the health of their children, not to mention their own.
Where women are excluded, health systems cannot adequately address women’s needs. There are a variety of reasons for this, many of them external to the health sector: culture and tradition, financial constraints and illiteracy, among others. All of them add up to discrimination.
The health of society cannot be assured unless women’s rights to equality and full participation are assured – and it is essential that health programmes recognize and fully address that fact.
Mr. President, UNICEF's commitment to the realization of children’s rights, as set out in the Convention on the Rights of the Child, is why UNICEF spends one third of its total funds on programmes aimed at improving child health. UNICEF's commitment – and the commitment of its partners, who include so many of you here today – are major reasons why the lives of more than 2 million young children a year are now being saved through a combination of prevention and primary care.
These commitments and these partnerships are why the eradication of poliomyelitis and guinea-worm disease is imminent, with measles soon to follow.
They are why the nutritional benefits of mothers breastfeeding their infants is beyond dispute, and why the unethical promotion and distribution of breastmilk substitutes has been significantly reduced.
These and other encouraging developments documented by the Secretary-General’s Mid-Decade Review of Progress for Children show how far we have come.
But they are also a good indication of how much work still remains to implement the goals of the World Summit for Children. For despite the gains in the overall health of children and women over the last 20 years, the health challenges we face are growing ever more complex and daunting. And as I noted, this is happening at a time when health and development assistance to developing countries continues to decline.
Distinguished Delegates, UNICEF will redouble its efforts to work with you and other partners to ensure the right of every child and every woman to quality essential health care. And it is vital that this important Conference come up with measures that will ensure that the Bamako Initiative fulfils its historic promise.