The Bamako Initiative aims to improve access to essential medicines in developing countries. It establishes drug revolving funds, where medicines are sold to consumers at low prices and the proceeds are used to purchase more medicines, creating a self-sustaining system. The initiative decentralized healthcare management to districts and communities. It has increased access to affordable medicines for over 60 million people, though it faces ongoing challenges like inadequate funding, poor supervision, and abuse of exemption policies. Recommendations to strengthen it include improved monitoring, orientation programs for local leaders, and incentives for community health workers.

1. Bamako Initiative
Dr Solomon Oluremi Olayinka
Community Medicine Department
Ekiti State University

2. Introduction
• “For countless patients around the world, the administration of a drug or a vaccine is the
embodiment of health care. Without drugs, a health service has no substance and no
credibility”.
• Essential drugs are those drugs that satisfy the health needs of the great majority of the
people and which should be available at all times in adequate and appropriate forms.
• They are those basic drugs that must be available for the treatment of the common
diseases in an area.

3. DRUG REVOLVING FUND
• An important aspect of the national essential drugs programme is the
principle of cost recovery.
• Drugs are sold to the consumers and the proceeds from the sales are
used to purchase replacement, which are in turn sold.
• The price paid by users for the drugs should be kept low as much as
possible but without running at a loss.
• This is achieved by efficient procedure, in particular, bulk purchase of
generic drugs.

4. DRUG REVOLVING FUND
• Drug revolving fund (DRF) can be defined as the recycling of fund set
aside for essential drugs programme to develop a cost-recovery
mechanism based on the sale of drugs to help overcome the financial
constraint on drug supply.
• In establishing a cost-recovery mechanism, care should be taken to set
prices at levels that are affordable to those intended to benefit from the
programme.
• The prices charged must not be higher than the market prices if the
programme is to be patronized by the consumers.

5. DRUG REVOLVING FUND
• Other factors to be taken into consideration in setting prices include
operational costs, overheads, currency fluctuation, etc.
• Provision should also be made for exemptions of certain categories of
people e.g. destitute, paupers, tuberculosis, leprosy and cancer
patients, and in some places, children.
• Costs of drugs used for such persons, as well as loses due to theft and
deterioration of drugs should be built into the fees charged, if possible.
• It has been shown that cost recovery accompanied by a fair supply of
essential drugs and by better-motivated staff improved the efficiency
of the health system

6. BAMAKO INITIATIVE
• WHO African Region in collaboration with UNICEF in Bamako, Mali
1987, put up a proposal which was aimed at enhancing the quality of
health services delivered to the people of the continent through:
a) Setting up a cost-recovery of an initially donated supply of essential
drugs at district (or LGA) level;
b)Ensuring a regular supply of essential drugs of good quality and at
lowest cost to support implementation of primary health care
c) Encouraging social mobilization initiatives to promote community
participation in policies of essential drugs and maternal and child
health at district (or LGA) level. This proposal forms the basis of
what has come to be known as the Bamako Initiative.

7. BAMAKO INITIATIVE
• Nigeria adopted the programme in 1988 and commenced in 1989 with financial and
technical support from the World Health Organization (WHO), United Nations Children’s
Fund (UNICEF) and the UK Department for International Development (DFID).
• The limited resources available restricted the development of B.I. to the status of a pilot
project, being available in only 57 out of 774 LGAs of the country. Even then, most of the
DRFs were decapitalized through reckless financial management by top LGA officials
and by their persistent failure to release approved funds for PHC and supervisory visits.
• In 1997/98, the Petroleum (Special) Trust Fund (PTF) set up by the Federal Government
provided enough resources (drugs) for all LGAs in Nigeria to commence the programme.

8. BAMAKO INITIATIVE
• Bamako Initiative involves steps to provide safe, efficacious and affordable
drugs at all times to all members of the community, thereby abolishing the
notorious out-of-stock syndrome in all the health centres, increasing
acceptance and utilization of available service.
• B.I. drugs are to be dispensed at the lowest price dictated by a good local
market survey. This makes the drugs affordable to most members of the
community.
• It was also hoped that by empowering the communities to own and manage
the drugs using management committees, the enabling environment for
social mobilization and full participation of the community in development
will be achieved.

9. REASONS WHY BI WAS DECLARED IN 1987
 Shortage of drugs and items.
 Degrading governmental (public) health services.
 Corruption and self-service by the demoralised healthcare staff.
 Personnel was plethoric but often not present at the working place.
 Inadequate and irregular salaries.
 Centralisation of decision making in governmental health systems.
 Staff movement, allocation of supplies, control and sanctions were teleguided by usually
ineffective and partially corrupt central bureaucracies.
 Etc.
 From these situations a big majority of the population was badly suffering. Drug shelves in
state dispensaries were empty for months. Only the rich could afford to go and buy drugs in
the private pharmacy or to drive to town to a private practice or a charging hospital.

10. REASONS FOR DRUG SHORTAGES
• Absence of an essential drugs list (to ensure good supplies of the most
commonly used drugs).
• Inadequate foreign exchange (to import the necessary raw materials to produce
the drugs within the country).
• Drug loss due to theft.
• Drug loss due to poor storage.
• Drug loss due to expiration.
• Drug loss due to irrational drug use (over-prescription, unnecessary injections,
incorrect prescriptions, etc.)
• Drug loss due to poor patient adherence (patients may also waste drugs they
have been prescribed if they are not sure of the correct dosage, lack confidence in
the health staff or fail to complete a course of treatment because they feel better).

11. GOALS OF BAMAKO INITIATIVE
• Bamako Initiative exemplifies the philosophies of social justice, fairness
and equity with respect to distribution and allocation of health care
resources. The programme is committed to:
1. Improving primary health care services for all.
2. Decentralizing the management of primary health services to district levels.
3. Decentralizing the management of locally collected patient fees to
community level.

12. GOALS OF BAMAKO INITIATIVE
4. Ensuring consistent fees are charged at all levels for health services- whether in
hospitals, clinics or health centres.
5. High commitment from governments to maintain and, if possible expand primary
healthcare.
6. National policy on essential drugs should be complementary to primary health
care.
7. Ensuring the poorest has access to primary healthcare.
8. Monitoring clear objectives for curative health services.

13. SUCCESSES OF BAMAKO INITIATIVE
The success of the B.I. can be traced directly to three major factors:
 the willingness of leaders at all levels of the health sector to be effective
communicators;
 the solid technical excellence that can be found even in small-scale projects,
 the flexibility of the initiative itself, which, instead of fixed, top down measures,
offers a set of strategies for revitalizing health services that can be adapted to a
wide variety of situations and cultural contexts.

14. SUCCESSES CONT’
1. In Africa alone, the B.I. has helped ensure access to affordable and sustainable primary
health services for more than 60million people through the revitalization of 6,000 health
centres- managed and partially funded by local commodities or districts in countries in
countries like Cameroon, the Gambia, Mali, Nigeria, and Togo.
2. In West Africa, 30% of all health centres in 15 nations have been revitalized. Indeed,
some countries, like Benin, Guinea and Senegal, have succeeded in strengthening
virtually all of their primary health centres with additional help from the World Bank and
bilateral partners.
3. Availability of good quality drugs all year round for treatment purposes at the
community level.
4. Increased patronage and utilization of health facilities by the community members.

15. SUCCESSES CONT’
5. Accessibility to good quality drugs by all and sundry.
6. Enhanced community sense of project/programme ownership.
7. Improved community level managerial capacities to manage programmes.
8. Increased community self-reliance on healthcare service delivery and
management.
9. Establishment of community level managerial structure such as Village
Development Committee, etc
• The last 7 achievements were recorded in Akinyele LGA of Oyo state.

16. CHALLENGES
1. Non-willingness of the formal health workers to decentralize authority and
responsibilities to community members.
2. Constant changes in government health policy which paralyzed the initiative.
3. Inadequate provision of logistic support for drug distribution. In a study, 89% of
respondents were willing to pay for health services if drugs were readily available.
4. Poor supervision, monitoring and evaluation by health workers.
5. Inadequate re-training or orientation for different categories of PHC workers at state and
LGA levels.

17. CHALLENGES
6. Abuse of exemption mechanism by the community members, thus
depleting the drug capital.
7. Poor information management system.
8. No definite form of incentive to the community level operators like
the village health workers, which contributes to the high rate of attrition.

18. 9. Long waiting queues, providers’ behaviours and lack of doctors
militates against the utilization of maternal and child health services.
10. Over-prescription and irrational drugs use. B.I. health centres had an
averaged of 5.3 drugs per prescription against 2.1 in the non-B.I. health
centres.

19. RECOMMENDATIONS
1. There is the need for national orientation/advocacy workshops/seminars for the
newly elected LGA and state policy makers to ensure their proper disposition to
health matters. This should provide ample opportunity for the agency to properly
brief these policy makers on priority health activities, their expected roles and
responsibilities to their people and the need to support their field staff.
2. The National Primary Health Care Development Agency (NPHCDA) should
undertake routine monthly monitoring visits to the LGAs to ensure that the
current B.I. efforts are sustained.

20. RECOMMENDATIONS
3. All LGAs which are yet to open their B.I. account should be made to do so.
4. The selling price of the drugs must logically be fixed locally following a carefully
conducted market survey by the relevant management committee to avoid the drugs
expiring unutilized, and to facilitate achievement of the objectives.
5. There should be re-training or orientation for different categories of PHC staff at
all levels on the operational guidelines in the Bamako Initiative management
manual.
6. Incentives and remuneration should be provided for all PHC staff.
7. Inter-sectoral collaboration is crucial to successful development of PHC and
comprehensive rural development.

21. CONCLUSION
• I believe that the success of the Bamako Initiative can be attributed to the
innovation of the leaders of the health sector and the flexibility of the
initiative itself, instead of fixed, top-down measures. It is adaptable to a
wide variety of situations and cultural contexts and gives plenty room for
community participation.
• However, challenges such as the deteriorating economic conditions and
frequent changes in government have contributed to the setbacks
experienced by the programme.