McPake B, Hanson K, Mills A
Health Economics and Financing Programme, London School of Hygiene and Tropical Medicine, U.K.
Soc Sci Med. 1993 Jun;36(11):1383-95. doi: 10.1016/0277-9536(93)90381-d.
The Bamako Initiative, a controversial attempt to strengthen Primary Health Care using community financing and community participation and management was launched at a meeting of African Ministers of Health in 1987. This evaluation focuses particularly on the community financing aspects of the Initiative. Previous experiences of community financing highlight particular lessons for the development of the Initiative and issues likely to be encountered in implementation attempts. Four country case studies of the Initiative at its early stages of implementation (in June, July and August 1991) were conducted in Burundi, Guinea, Kenya, and Nigeria. Similar activities in Uganda were also studied. These were short studies of one month each and utilised methods of rapid evaluation. The studies aimed to direct implementers quickly to issues requiring attention rather than to reach overall conclusions regarding the success of the Initiative which would be premature at this stage. Price structures used by the Initiative need to consider the access of marginalised groups more than is the case at present. In addition, there is a need to ensure against over-prescription and commercialisation and to ensure that incentives for utilising most appropriate levels of care are maintained. The evidence suggests that most people do find amounts of money to pay for health services which are large in relation to their income. This is probably a tribute to extensive community support mechanisms. Nevertheless, it highlights the plight of those who fall through this safety net for whom even charges for very basic care may be prohibitive. On the other hand, it appears that in most cases, the Initiative's activities provide a service which is cheaper when all costs to the household are taken into account, than was available before. The quality of services included in the Initiative's activities in the five countries was highly variable. Success in raising substantial revenues has also been mixed. In some countries however, substantial funds have been generated and used to achieve real improvements in health services. Overall, the experiences of the five countries appear to have been highly dependent on a number of 'environmental' characteristics: a tradition or not of 'free' services; the adequacy of current resource availability and that immediately preceding the introduction of the Initiative; the existing stage and nature of decentralisation within the country; and the competition the Initiative's activities face with alternatives.
巴马科倡议是1987年在一次非洲卫生部长会议上发起的，旨在通过社区筹资以及社区参与和管理来加强初级卫生保健，这一尝试颇具争议。本次评估特别关注该倡议的社区筹资方面。以往社区筹资的经验为该倡议的发展提供了特别的经验教训以及实施过程中可能遇到的问题。1991年6月、7月和8月，在布隆迪、几内亚、肯尼亚和尼日利亚对该倡议实施初期阶段进行了四个国家的案例研究。还对乌干达的类似活动进行了研究。这些都是为期一个月的简短研究，并采用了快速评估方法。这些研究旨在迅速引导实施者关注需要注意的问题，而不是在现阶段就该倡议的成功得出总体结论，因为这还为时过早。该倡议所采用的价格结构需要比目前更多地考虑边缘化群体的可及性。此外，有必要防止过度开药和商业化，并确保维持使用最合适护理水平的激励措施。有证据表明，大多数人确实会拿出与收入相比数额较大的钱来支付医疗服务费用。这可能要归功于广泛的社区支持机制。然而，这凸显了那些未能受益于这一安全网的人的困境，即使是非常基本的护理收费对他们来说也可能过高。另一方面，似乎在大多数情况下，考虑到家庭的所有成本，该倡议的活动所提供的服务比以前更便宜。该倡议在五个国家开展的活动所包含的服务质量差异很大。在筹集大量资金方面的成功情况也参差不齐。然而，在一些国家，已经筹集了大量资金并用于切实改善医疗服务。总体而言，这五个国家的经验似乎高度依赖于一些“环境”特征：是否有“免费”服务的传统；当前资源的充足程度以及在该倡议实施之前紧接的资源充足程度；该国现有的权力下放阶段和性质；以及该倡议的活动所面临的与其他替代方案的竞争。
