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Abstract

Under the Bamako initiative UNICEF will provide free drugs to participating countries for the 1st few years; drugs will be sold to patients; and communities will control the finances. The aims are to establish a revolving drug fund to pay for future drug supplies and to use leftover money to maintain and improve primary health care services. Several problems with the initiative are foreseen. Firstly charging users may reduce utilization by the poor. Although UNICEF agrees that provision of free service for indigents in necessary systematic identification of these people may be difficult. Secondly financing will be difficult to implement given the rarity of managerial skills and the poor quality of local supervision. The sustainability of the initiative is also in doubt. UNICEF initially proposed large mark ups on the basic cost of the drugs; now partial recovery of the cost is proposed although how charges will be set is unclear. The question of whether services will be dependent when the free drugs stop remains to be answered. A further objection to the scheme is the almost inevitable deterioration of rational prescribing; paying patients will feel justified in demanding drugs and injections. UNICEFs solutions and strategies for implementation of policy remain vague and lack attention to detail. For instance initial training courses aide community management of drug funds but there is no commitment to continued support and local evaluation. Other sources of funding need to be considered. Host governments should commit to continued financial and supervisory input and to maintaining control over their own health services. Communication between staff and government should be established and maintained. Gradual and sensitive introduction with careful monitoring of equity utilization and rational drug use is essential to prevent failure of this important proposal.
whereas
Listeria
monocytogenes
is
commonly
found
in
the
environment
and
in
food.
Nevertheless,
the
aetiology
of
listeriosis
will
not
be
properly
understood
until
we
have
better
information
on
the
incidence,
levels
of
contamination,
and
conditions
for
survival
and
destruction
of
listeria
in
a
wide
variety
of
foods.
With
very
few
exceptions,45
sporadic
cases
of
listeriosis
have
not
been
linked
with
the
consumption
of
any
particular
food.
Foods
implicated
in
the
outbreaks
of
listeriosis,
such
as
raw
vegetables,6
coleslaw,7
milk,8
and
soft
cheeses,9
have
generally
been
eaten
without
further
heating.
Meat
pate
is
the
latest,
but
surely
not
the
last,
casualty
in
the
hunt
for
listeria
in
food.
Although
cook-chill
catering
has
been
the
subject
of
concern,
adequate
reheating
of
cook-chill
meals
will
substan-
tially,
though
not
completely,'0I'
reduce
the
risk
of
consuming
micro-organisms
that
may
have
multiplied
during
chill
storage.
The
Department
of
Health's
revised
and
recently
published
guidelines
on
cook-chill
and
cook-freeze
catering
systems'2
include
the
requirements
that
L
monocytogenes
should
not
be
detectable
in
25
g
of
food
at
the
end
of
chill
storage;
that
reheating
should
achieve
a
core
temperature
of
at
least
70°C
for
two
minutes;
and
that
the
food
should
be
served
as
soon
as
possible
and
in
any
case
within
15
minutes
of
reheating.
More
research
into
the
safety
of
cook-chill
and
other
modern
forms
of
food
provision
is
urgently
needed.
The
recommendation
from
the
Social
Services
Committee
that
the
government
should
review
its
policy
to
withdraw
funding
from
agricultural
and
food
research
for
the
"public
good"
and
should
continue
to
support
such
research
actively
even
when
it
falls
into
the
category
of
"near
market"
research
is
to
be
applauded.'
There
is,
however,
an even
more
pressing
need
for
national
case-control
studies
to
address
the
many
un-
answered
questions
in
the
epidemiology
of
listeriosis.
Such
a
study
was
started
recently
by
the
Communicable
Diseases
(Scotland)
Unit,
and
a
pilot
study
by
the
Communicable
Diseases
Surveillance
Centre
is
now
under
way
in
England
and
Wales.
Until
better
information
is
available
we
lack
a
sound
basis
for
rational
decisions
about
the
control
of
listeriosis
and
"listeria
hysteria"
will
continue
to
flourish.
P
J
WILKINSON
Director,
Microbiology
and
Public
Health
Laboratory,
Derriford
Hospital,
Plymouth
PL6
8DH
I
House
of
Commons
Social
Services
Committee.
Sixth
Report.
Food
Poisoning:
Li'steria
and
Listertosis.
London:
HMSO,
1989.
2
Warden
J.
Listeriosis
warning
too
late.
BrMed_7
1989;299:78-9.
3
Department
of
Health
and
Social
Security,
Review
of
Public
Health
Laboratory
Service.
London:
DHSS,
1984.
4
Kerr
KG,
Dealler
SF,
Lacev
RW.
Miaterno-fetal
listeriosis
from
cook-chill
and
refrigerated
food.
La.tctt
1988;ii:
1
!33.
5
Centres
tor
l)isease
Control.
Listeriosts
associated
with
consumptton
of
turkey
franks
IMWM'R
1989;38:267-8.
6
Ho
JL,
Shand
SKN,
Frieland
G,
Eckind
P,
Fraser
DW.
An
outbreak
of
type
4h
Listeria
monoc-vtogenes
infection
involving
patients
from
eight
Boston
hospitals.
Arch
Intern
Med
1986;146:520-4.
7
Schlech
WF,
Lavigue
PM,
Bortolussi
RA.
Epidemic
listcriosis:
evidcnce
for
transmission
by
food.
N
Englj
Med
1983;308:203-6.
8
Fleming
DW,
Cochi
SL,
MacDonald
KL,
et
al.
Pasteurized
milk
as
a
vehicle
of
infection
in
an
outbreak
of
listeriosis.
N
Engli]
Med
1985;312:404-7.
9
Linnan
MJ,
Mascola
L,
Lou
XD,
et
al.
Epidemic
Listeriosis
associated
with
Mexican-style
cheese.
N
Engl_7.Med
1988;319:823-8.
10
LuLnd
BM,
Knox
MR,
Cole
MB.
l)estructton
of
Listeria
monocytogenes
during
microwave
cookinig.
Lancet
1989;i:218.
11
Sandys
GH,
Wilkinson
PJ.
Microbiological
evaluLation
of
a
hospital
delisered
meals
service
using
precooked
chilled
foods]
Hosp
Infect
1988;ii:209-19.
12
Department
of
Health.
Chilled
and
frozen:
guidelines
on
cook-chill
and
cook-freeze
catering
systems.
London:
HMSO,
1989.
The
Bamako
initiative
Financing
health
in
Africa
by
selling
drugs
To
treat
a
child
with
pneumonia
for
$2.50
may
seem
a
bargain,
but
in
Mozambique
this
might
be
more
than
a
tenth
of
a
family's
monthly
income.I
This
is
an
example
of
one
of
the
dilemmas
facing
the
United
Nations
Children's
Fund
(Unicef)
through
its
proposal
to
sell
drugs
at
a
profit
to
help
fund
primary
health
care
in
the
countries
of
subSaharan
Africa.2
The
Bamako
initiative-so
called
because
it
was
introduced
at
a
meeting
of
African
health
ministers
in
Bamako,
Mali-is
poised
to
start:
Unicef
will
provide
free
drugs
to
participating
countries
for
the
first
few
years;
the
drugs
will
be
sold
to
patients;
and
communities
will
control
the
finances.
The
aims
are
to
establish
a
revolving
drug
fund
to
pay
for
future
drug
supplies
and
to
use
money
left
over
to
maintain
and
improve
primary
health
care
services.
The
initiative
arose
in
response
to
the
increasing
poverty
and
reducing
resources
for
health
care
in
Africa
caused
by
falling
commodity
prices
and
the
strain
of
loan
repayments.
There
is
simply not
enough
money
for
health.
The
Bamako
initiative
is
a
fresh
strategy
to
finance
health
services
and
prevent
them
collapsing
completely.
Though
new
ideas
are
desperately
needed,
organisations
and
staff
working
in
Africa
are
concerned
that
selling
donated
drugs
may
not
be
the
answer.
3
4
Equity
is
at
risk:
charging
users
may
reduce
utilisation
by
the
poor.
Unicef
maintains
that
people
are
willing
to
pay,
but
the
real
issues
are
whether
they
are
able
to
and
at
what
cost
to
themselves
and
their
families.
Although
Unicef
agrees
that
provision
of
free
service
for
"indigents"
is
necessary,'
identifying
these
people
presents
problems.
Discretionary
powers
are
likely
to
rest
with
health
staff,
who
will
come
under
strong
pressure
to
provide
free
services
to
friends,
family,
and
others
to
whom
they
are
obliged.
The
penniless
may
stay
away
from
fear
of
being
asked
for
money.
Others
may
wish
to
avoid
the
humiliation
of
being
labelled
indigent.
The
innovative
idea
of
community
financing
will
be
difficult
to
implement.'
Rural
populations
are
expected
to
manage
the
money
collected
from
drug
sales
and
decide
how
it
will
be
spent
in
improving
and
extending
primary
health
care
services.
In
many
countries
managerial
skills
are
rare
and
local
supervision
poor;
administration
is
thus
likely
to
be
chaotic.
Misappropriation
and
mismanagement
of
funds
could
easily
occur.
In
a
scheme
in
Ghana
fees
collected
were
not
even
reaching
the
fund;
they
were
being
kept
by
the
doctor.'
Whether
the
initiative
can
be
sustained
is
also
in
doubt:
Unicef
initially
proposed
large
mark
ups
on
the
basic
cost
of
the
drugs;
now
partial
recovery
of
the
cost
is
proposed,
although
how
charges
will
be
set
is
unclear.
Revenue
will
be
in
local
currency
and
thus
will
buy
few
replacement
drugs
from
overseas.
What
will
happen
when
the
free
drugs
stop?
The
Bamako
initiative
could
inadvertently
result
in
health
service
financing
being
dependent
on
a
continuous
supply
of
drugs
from
donors.
In
fact
many
countries
could
make
substantial
savings
without
charging
by
introducing
an
essential
drugs
policy
along
the
lines
advocated
by
the
World
Health
BMJ
VOLUME
299
29
JULY
1989
277
Organisation,
establishing
a
national
drugs
list,
importing
generic
drugs
at
low
cost,
and
ensuring
proper
storage
and
distribution.
A
further
objection
to
the
scheme
is
the
almost
inevitable
deterioration
of
rational
prescribing:
paying
patients
will
see
it
as
their
right
to
demand
drugs
and
injections,
which
may
be
inappropriate;
and
health
staff
will
be
under
pressure
to
prescribe
if
their
salary
depends
on
drug
profits.
Unicef
recognises
the
enormous
problems
of
implementing
the
policy,
yet
its
solutions
and
strategies
remain
vague.
Community
management
of
revolving
drug
funds
is
dealt
with
by
initial
training
courses,
but
there
is
no
commitment
to
continued
support
and
evaluation
locally.
Unicef
still
expects
to
scale
up
schemes
rapidly
in
participating
countries
to
nationwide
implementation;
yet
suddenly
introducing
the
initiative
with
so
many
changes
and
little
attention
to
detail
is
likely
to
be
counterproductive.
Unicef
has
been
criticised
before
for
dreaming
up
global
solutions
organised
from
the
top
down.7
Much
basic
spade
work
must
be
done
locally
to
ensure
that
the
scheme
is
properly
understood.
Other
sources
of
funding
-whether
through
risk
sharing,
insurance
schemes,
or
taxation-need
to
be
considered.8
Host
governments
should
commit
themselves
to
continued
financial
and
supervisory
input
and
to
maintaining
control
over
their
own
health
services.
Avenues
of
communication
between
participating
staff
and
governments
need
to
be
established
and
maintained
to
share
the
experiences
of
financing
schemes.
Gradual
and
sensitive
introduction,
with
careful
monitoring
of
equity,'
utilisation,
and
rational
drug
use
from
the
outset,
is
essential
to
prevent
failure
of
this
important
proposal.
PAUL
GARNER
Research
Fellow,
Evaluation
and
Planning
Centre
for
Health
Care,
London
School
of
Hygiene
and
Tropical
Medicine,
London
WC
1
E
7HT
I
Kanji
N.
C(harging
for
drugs
in
Africa:
UNICEF's
"Bamako
initiative."
Health
Policy
and
Planning
1989;4:110-20.
2
Grant
Jl'.
Af'rica:
the
Bamako
initiatisve.
In:
Unicef.
The
state
of
the
world's
children
1989.
Oxford:
Oxford
University
Press,
1989:50.
3
Anonymous.
The
Bamako
initiative
[Editorial].
Lancet
1988;ii:
1177-8.
4
Chabot
J.
'I'he
Bamako
initiative.
Lancet
1988;ii:
1366-7.
5
Unicef.
'[he
Bamako
initiative.
New
York:
Unicef,
1988.
(Mimeograph
E/ICEF/1988/I'/L40.)
6
VWaddington
CJ,
Envimavew
KA.
A
price
to
pay:
the
impact
of
user
charges
in
Ashanti-Akim
district,
Ghana.
InternationalJ7ournal
of
flealth
Planning
and
Management
1989;4:17-47.
7
Wisner
B.
GOBI
versus
PHC?
Some
dangers
of
selective
primary
health
care.
Soc
Sci
Med
1988;26:963-9.
8
Hoare
G.
P'olicies
for
financing
the
health
sector.
Health
Policy
and
Planning
1987;2:1-16.
Improving
the
results
of
treating
gastric
cancer
Demands
earlier
diagnosis
and
better
surgery
In
England
and
Wales
about
10
000
people
die
each
year
from
carcinoma
of
the
stomach,'
and
at
diagnosis
only
about
1%
of
cases are
early
(carcinoma
confined
within
the
submucosa).'
The
Japanese,
motivated
by
having
an
incidence
of
the
disease
about
three
times
that
in
Britain,
have
increased
the
proportion
of
cases
of
the
disease
that
are
diagnosed
early
from
2%
in
19553
to
30%
in
1978.'
By
adhering
to
a
set
of
rules
for
describing
the
condition
and
its
stage5
they
have
made
possible
accurate
assessment
of
results.
Their
widespread
use
of
extended
lymphadenectomy
is
now
well
known:
in
this
procedure
(known
as
R2
resection)
an
extra
"tier"
of
lymph
nodes
is
removed
in
addition
to
those
close
to
the
stomach
that
are
normally
removed
in
a
conventional
gastrectomy
(known
as
R
1
resection).
The
merits
of
this
operation
have
not
yet
been
proved
by
a
controlled
trial,
but
its
use has
yielded
much
valuable
information
about
lymph
node
metastasis.
Nodes
containing
tumour
are
often
not
enlarged
or
hard,
so
that
up
to
three
quarters
of
them
are
impossible
to
detect
macroscopically.67
The
tumour
is
identified
only
by
pains-
taking
dissection
of
fresh
specimens
obtained
at
gastrectomy
and
careful
histological
examination
by
the
methods
described
in
the
Japanese
rules.
If this
is
not
done
understaging
may
occur.
In
Japan
lymph
node
metastases
are
present
in
about
one
in
seven
of
early
cases;
with
increasing
invasion
by
the
tumour
into
and
then
out
of
the
gastric
wall
this
proportion
increases
and
the
prognosis
worsens.4
About
a
third
of
patients
in
whom
the
serosa
has
been
reached
have
metastatic
tumour
in
their
lymph
nodes.4
When
the
serosa
is
penetrated
the
proportion
rises
to
four
fifths,
and
over
a
third
of
the
affected
nodes
are
in
the
second
tier
(known
as
N2
nodes)4
5;
this
is
beyond
the
reach
of
the
standard
resection
in
Britain.
Most
patients
in
Britain
present
with
the
serosa
already
penetrated,
and
in
over
80%
the
lymph
nodes
have
been
affected.8
The
results
of
treatment
in
Japan
have
not
been
equalled
elsewhere.
Of
5959
new
cases
of
gastric
cancer
that
were
assessed
after
five
years
in
1978,
resections
had
been
per-
formed
in
4605
(77%)
and
extended
lymphadenectomy
in
3673
(80%
of
resections).
The
age
corrected
five
year
survival
after
resection
was
81%
for
patients
with
lesions
confined
within
the
serosa
(with
or
without
disease
in
the
lymph
nodes)
and
30%
for
those
with
more
advanced
disease.4
Overall
survival
after
resection
was
60%,
and
the
30
day
postoperative
mortality
was
under
2%.'
These
results
are
challenging
when
compared
with
the
British
age
corrected
five
year
survival
of
4%.
Survival
in
Britain
was
improved
to
only
17%
by
resection,
which
was
possible
in
only
27%
of
cases.2
We
do
not
know
the
relative
contributions
to
the
better
results
of
early
diagnosis
and
better
surgery;
nor
do
we
know
whether
the
Japanese
disease
behaves
in
a
less
aggressive
way
than
the
British
version.
The
remarkable
improvement
in
early
diagnosis
in
Japan
has
gone
hand
in
hand
with
improved
survival.
3
The
main
advaiitage
of
extended
lymphadenectomy
may
lie
in
its
use
in
patients
who
have
disease
in
only
the
first
tier
of
lymph
nodes
(N
1
nodes):
the
five
year
survival
in
such
patients
is
26%
in
those
who
have
had
the
conventional
operation
and
63%
in
those
who
have
had
an
extended
lymphadenectomy.4
The
apparently
normal
N2
nodes
removed
by
the
extended
lymphadenectomy
may
contain
micrometastases
that
are
not
detectable
even
by
the
Japanese
methods.
The
data
must
be
interpreted
with
caution,
however,
because
histologically
detectable
disease
in
the
second
tier
of
nodes
may
have
been
missed
by
the
conventional
resections.
But
an
extended
resection
in
Japan
cures
a
third
of
patients
who
have
cancer
in
the
second
tier
of
nodes,
and
a
conventional
resection
is
fruitless
in
such
patients.
Most
of
the
cures
were,
however,
in
patients
whose
disease
had
not
passed
through
the
serosa.4
Such
patients
(serosa
negative,
N2
positive)
are
rarely
encountered
at
present
in
Britain.
Data
are
scanty
on
the
effect
of
the
type
of
operation
on
patients
with
serosal
invasion.
Four
fifths
of
the
Japanese
patients
in
this
category
had
cancer
cells
only
on
the
surface
of
the
serosa,
and
a
third
of
this
group
survived
five
years.
Only
17%
of
those
with
infiltration
into
surrounding
tissue
survived
five
278
BMJ
VOLUME
299
29
JULY
1989
... In the Bamako Initiative, a joint WHO/ United Nations Children's Fund (UNICEF) Initiative aimed at solving the problems in the financing of primary health care in sub- Saharan Africa was launched in September 1987 at a re- gional WHO meeting [20,21]. During this meeting, the director of UNICEF dealt with the severe economic crises facing sub-Saharan Africa, the negative effects of adjust- ment programs on health, and the reluctance of donors to continue to fund recurrent costs of primary health care programs [22]. ...
... Accordingly, the pooling of communities for financial participation in the health system, particularly regarding the care of PLWH and provision of ART is in line with the Bamako Initiative [20][21][22]. Thus, the establishment of mutual will generate local funding that could constitute a special fund not only for the acquisition of drugs in the long term but also for the functioning of community-based organizations. ...
Article
Full-text available
Background The advent and widespread use of antiretroviral therapy (ART) has remarkably changed the paradigm of HIV infection, increasing substantially the lifespan and quality of life of people affected. Accordingly and responding to policy makers and international directives, many strategies were put in place in Cameroon to accelerate ART uptake, including the community dispensation of ART through community-based organizations (CBOs). Main body In its strategic plan to curb the burden of HIV/AIDS and as part of accelerating and reinforcing the provision of ART to all people living with HIV (PLWH), Cameroon opted for different strategies including the dispensation of ART in the community through well identified and tutored CBOs. Actually, financing of ART in Cameroon is mainly the conjugation of resources from the Government and its technical and financial partners, basically the Global Funds supplemented by supports from the Unitaid initiative which allows PLWH residing in Cameroon to benefit from continuous ART without spending a dime. However, this external funding will end-up by 2020. Therefore, there is urgent need to think of alternative and efficient strategies to sustain the fight against HIV/AIDS in Cameroon, especially the provision of ART to patients through community dispensation. Some studies carried out in sub-Saharan African countries have shown that mutual health insurance seems to be a solution with great potential to improve access to quality care, mobilize the necessary funds, improve efficiency of the health sector, and promote dialogue and democratic governance in the health sector along with social and institutional development of the society. Conclusions The pooling of associations of PLWH in Cameroon and other countries of sub-Saharan Africa in line with the Bamako Initiative constitutes a promising strategy that would undoubtedly help to offset the withdrawal of funding from external sources, and allow an appropriation of the fight against HIV/AIDS by those concerned at the first place. Nevertheless, other lines of research of financing could be explored in the economic sector.
... In developing countries, cost recovery mechanisms such as the Bamako Initiative, cost sharing and community-based financing schemes like mutual health funds complemented public sector grants. 3 These measures have not, however, curbed growing deficits, negative performance and poor quality of healthcare. More than fifty percent of health funding comes from out of pocket expenditure. ...
Article
Full-text available
The Yaoundé Gynaeco-Obstetric and Pediatric Hospital (YGOPH) faced challenges of high debts and sub-optimal care delivery. Performance-Based-Management (PBM) provides an environment of checks and balances, increased transparency, competition and autonomy, thereby improving clinical as well as financial indicators. We describe the transition from resource-based to PBM at the YGOPH over a seven-year period. There was an increase of 4.5% in OB/GYN and 8.1% in prenatal consultations, 8.4% in C-sections, 6.1% of children vaccinated, and 30.5% of women seen for family planning, 51.1% of people living with the Human Immunodeficiency Virus on treatment and 29.4% of indigent patients. These results occurred in spite of a 14% reduction in staff. Annual revenue increased by 5.75%. The share of hospital income from care on overall hospital revenue increased from 55.11% to 60.00%. With this self-financing PBM model, the hospital remains a social, humane and financially viable structure delivering improved quality care.
... One innovative solution that can provide a back-up supply of medications when public-sector supply chains break down is the Revolving Drug Fund (RDF) model that has been implemented in multiple SSA countries. 70 Within the Kenyan implementation, the RDF provides sustainable access to medications when government pharmacies are out of stock, and has been shown to increase medication availability by at least 50%. 71 Comprehensive diabetes care requires multifactorial interventions including sustainable access to medications, medical supplies, and diagnostic tools for blood sugar, lipid, and renal function testing. ...
Article
Full-text available
Diabetes is a chronic non-communicable disease (NCD) presenting growing health and economic burdens in sub-Saharan Africa (SSA). Diabetes is unique due to its cross-cutting nature, impacting multiple organ systems and increasing the risk for other communicable and non-communicable diseases. Unfortunately, the quality of care for diabetes in SSA is poor, largely due to a weak disease management framework and fragmented health systems in most sub-Saharan African countries. We argue that by synergizing disease-specific vertical programs with system-specific horizontal programs through an integrated disease-system diagonal approach, we can improve access, quality, and safety of diabetes care programs while also supporting other chronic diseases. We recommend utilizing the six World Health Organization (WHO) health system building blocks - 1) leadership and governance, 2) financing, 3) health workforce, 4) health information systems, 5) supply chains, and 6) service delivery - as a framework to design a diagonal approach with a focus on health system strengthening and integration to implement and scale quality diabetes care. We discuss the successes and challenges of this approach, outline opportunities for future care programming and research, and highlight how this approach can lead to the improvement in the quality of care for diabetes and other chronic diseases across SSA.
... The concept of "revolving drug funds" (RDF) dates back to 1989 when an RDF project was initiated in Ghana. 50 In an RDF, seed funding is used to purchase an initial stock of medicines, which are then sold at a price point sufficient to support staff salaries and replace the initial stock. Building on the experiences and successes of RDF projects in other LMICs, 51,52 the Academic Model Providing Access To Healthcare (AMPATH) program in western Kenya created a network of revolving fund pharmacies (RFPs) in 2011 to address availability of affordable essential medicines. ...
Article
Cardiovascular disease (CVD) is the leading cause of global mortality and is expected to reach 23 million deaths by 2030. Eighty percent of CVD deaths occur in low-income and middle-income countries (LMICs). Although CVD prevention and treatment guidelines are available, translating these into practice is hampered in LMICs by inadequate health care systems that limit access to lifesaving medications. In this review article, we describe the deficiencies in the current LMIC supply chains that limit access to effective CVD medicines, and discuss existing solutions that are translatable to similar settings so as to address these deficiencies.
Article
Full-text available
Availability of medicines for treatment of cardiovascular disease (CVD) is low in low-income and middle-income countries (LMIC). Supply chain models to improve the availability of quality CVD medicines in LMIC communities are urgently required. Our team established contextualised revolving fund pharmacies (RFPs) in rural western Kenya, whereby an initial stock of essential medicines was obtained through donations or purchase and then sold at a small mark-up price sufficient to replenish drug stock and ensure sustainability. In response to different contexts and levels of the public health system in Kenya (eg, primary versus tertiary), we developed and implemented three contextualised models of RFPs over the past decade, creating a network of 72 RFPs across western Kenya, that supplied 22 categories of CVD medicines and increased availability of essential CVD medications from <30% to 90% or higher. In one representative year, we were able to successfully supply 5 793 981 units of CVD and diabetes medicines to patients in western Kenya. The estimated programme running cost was US$6.5–25 per patient, serving as a useful benchmark for public governments to invest in medication supply chain systems in LMICs going forward. One important lesson that we have learnt from implementing three different RFP models over the past 10 years has been that each model has its own advantages and disadvantages, and we must continue to stay nimble and modify as needed to determine the optimal supply chain model while ensuring consistent access to essential CVD medications for patients living in these settings.
Chapter
The right to access essential medicines and medical technologies is crucial to attain the highest-quality health care for all citizens of the world. Unfortunately, in many low- and middle-income countries (LMICs) around the world, patients’ ability to access quality essential medicines still remains a critical challenge. Barriers that impact the quality of essential medicines from chronic communicable and chronic non-communicable diseases lie within three specific areas (3A’s): availability, accountability, and adherence. First, unnecessarily complex supply chain management, poor operational procedures, and inadequate financing for health lead to low availability of medicines. Second, corruption contributes to falsified and substandard medicines and low accountability of the supply chain to the patients who rely on it. Lastly, poor patient adherence to medicines is affected by low health literacy, lack of communication between providers and patients, and social stigma of diseases. Based on our on-the-ground experiences working in western Kenya, we propose solutions that target each of these challenges to improve access and quality of medicines. Through this chapter, we hope to compel chemists to apply and focus their efforts to create transformative chemical techniques with the potential to significantly improve quality of medicines, to improve patient outcomes, and to alter the delivery of care to patients all over the world.
Article
This chapter on health care financing introduces financing as one aspect of the health system that affects health equity. The configuration of financing, defined as both mobilization of financial resources and the allocation of those resources to the population, will affect health outcomes in two important ways. First, it determines, in part, the availability of health care and who has access to it. Second, it dictates the degree of financial protection offered against catastrophic costs of illness. It is argued that although financing issues often tend to dominate debates and prescriptions for health systems reform, methods of financing are but one aspect of a broad health system that involves institutions, policies, and human resources.
Article
Full-text available
User fees have been shown to constitute a major barrier to the utilisation of health-care, particularly in low-income countries such as the Democratic Republic of Congo (DRC). Importantly, such barriers can lead to the exclusion of vulnerable individuals from health-care. In 2008, a donor-funded primary health-care programme began implementing user fee subsidisation in 20 health zones of the DRC. In this study, we quantified the short and long-term effects of this policy on health-care utilisation. Sixteen health zones were included for analysis. Using routinely collected health-care utilisation data before and after policy implementation, interrupted time series regression was applied to quantify the temporal impact of the user fee policy in the studied health zones. Payment of salary supplements to health-care workers and provision of free drugs - the other components of the programme - were controlled for where possible. Fourteen (88%) health zones showed an immediate positive effect in health-care utilisation rates (overall median increase of 19%, interquartile range 11 to 43) one month after the policy was introduced, and the effect was significant in seven zones (P <0.05). This initial effect was sustained or increased at 24 months in five health zones but was only significant in one health zone at P <0.05. Utilisation reduced over time in the remaining health zones (overall median increase of 4%, interquartile range -10 to 33). The modelled mean health-care utilisation rate initially increased significantly from 43 consultations/1000 population to 51 consultations/1000 population during the first month following implementation (P <0.01). However, the on-going effect was not significant (P =0.69). Our research brings mixed findings on the effectiveness of user fee subsidisation as a strategy to increase the utilisation of services. Future work should focus on feasibility issues associated with the removal or reduction of user fees and how to sustain its effects on utilisation in the longer term.
Article
Full-text available
Village health workers (VHWs) promote health and provide basic health care in areas of the world where basic health knowledge and health professionals are scarce. The 1960s-1980s saw a dramatic increase in the training of VHWs in resource-limited environments. Politics changed, disillusionment set in, and enthusiasm waned. Recently, increased pressures on health resources have led to the resurgence of VHWs. Until the shortage of health professionals is alleviated, the need for VHWs to extend the reach of scientifically verified health care into remote and conflict areas will remain acute. This need provides a compelling reason to pursue research concerning VHWs. Village health workers are usually trained by professional nurses and refer patients to them, so nursing is positioned to lead this important research. The author developed the concept of the VHW using Meleis's Integrated Approach. Meleis's approach was chosen because it is appropriate for undeveloped concepts, emphasizes exploration and discovery, and can begin with clinical practice, taking advantage of the author's experience with VHWs. The resultant concept definition, with antecedents and consequences, provides a foundation other nurse researchers can build upon. Existing research concerning VHWs was reviewed and gaps suitable for future nursing research were identified.
Article
Full-text available
Between June 30th and August 30th, 1983, 49 patients in Massachusetts acquired listeriosis. Seven cases occurred in fetuses or infants and 42 in immunosuppressed adults; 14 patients (29 per cent) died. Of 40 Listeria monocytogenes isolates available for testing, 32 were serotype 4b. Two case-control studies, one matching for neighborhood of residence and the other for underlying disease, revealed that the illness was strongly associated with drinking a specific brand of pasteurized whole or 2 per cent milk (odds ratio = 9, P less than 0.01 for the neighborhood-matched study; odds ratio = 11.5, P less than 0.001 for the illness-matched study). The association with milk was further substantiated by four additional analyses that suggested the presence of a dose-response effect, demonstrated a protective effect of skim milk, associated cases with the same product in an independent study in another state, and linked a specific phage type with the disease associated with milk. The milk associated with disease came from a group of farms on which listeriosis in dairy cows was known to have occurred at the time of the outbreak. Multiple serotypes of L. monocytogenes were isolated from raw milk obtained from these farms after the outbreak. At the plant where the milk was processed, inspections revealed no evidence of improper pasteurization. These results support the hypothesis that human listeriosis can be a foodborne disease and raise questions about the ability of pasteurization to eradicate a large inoculum of L. monocytogenes from contaminated raw milk.
Article
Recession and economic adjustment policies have led to massive resource shortages in government health systems in many less developed countries in Africa. There is growing evidence that the IMF- and World Bank-sponsored adjustment programmes are responsible for negative effects on the health of the poor in these countries. Calls for a New International Economic Order and 'adjustment' in the industrialized countries have been ignored and the resource flow from the poor to the rich countries continues. UNICEF is currently promoting 'Adjustment with a human face' as a means of alleviating poverty and minimizing the negative impact of adjustment on the poor. In the health sector, this approach concentrates on the GOBI-FFF strategy and the supply of essential drugs to primary level health services. UNICEF is also in the process of launching the 'Bamako Initiative' which aims, by introducing drug/treatment charges and setting-up revolving drug funds at community level, to finance drug costs, the operational costs of the MCH programme and the salaries of community health workers at primary level. Quite apart from the debatable long-term impact of the health strategy being advocated, the Bamako Initiative poses serious questions related to equity and the implementation of fee systems which must be answered.
Article
Throughout the developed and the developing world, health services are in trouble. Current policies have failed to mobilize enough financial, human and other resources to meet existing or anticipated needs. Health for All by the Year 2000, in identifying deficiencies in health and health services, has also drawn attention to deficiencies in the resources devoted to the health sector, and in health sector planning and financial analysis. Increasing attention is being focused on the subject of health service financing, on methods of planning and analysis, and on ways of bridging the health sector resource gap. This paper identifies some of the broad policy options for financing the health sector, and discusses them with respect to a number of questions: Who pays (and who benefits)? How much? For what? Through what mechanisms? A number of financing mechanisms are discussed within the frequently used classification of public and private sources of finance. The main features of each approach are summarized, and the major strengths and weaknesses discussed. Finally, directions for further research are indicated.
Article
In Los Angeles County, California, 142 cases of human listeriosis were reported from January 1 through August 15, 1985. Ninety-three cases (65.5 percent) occurred in pregnant women or their offspring, and 49 (34.5 percent) in nonpregnant adults. There were 48 deaths: 20 fetuses, 10 neonates, and 18 nonpregnant adults. Of the nonpregnant adults, 98 percent (48 of 49) had a known predisposing condition. Eighty-seven percent (81 of 93) of the maternal/neonatal cases were Hispanic. Of the Listeria monocytogenes isolates available for study, 82 percent (86 of 105) were serotype 4b, of which 63 of 86 (73 percent) were the same phage type. A case-control study implicated Mexican-style soft cheese (odds ratio, 5.5; 95 percent confidence interval, 1.2 to 24.8) as the vehicle of infection; a second case-control study showed an association with one brand (Brand A) of Mexican-style soft cheese (odds ratio, 8.5; 95 percent confidence interval, 2.4 to 26.2). Laboratory study confirmed the presence of L. monocytogenes serogroup 4b of the epidemic phage type in Brand A Mexican-style cheese. In mid-June, all Brand A cheese was recalled and the factory was closed. An investigation of the cheese plant suggested that the cheese was commonly contaminated with unpasteurized milk. We conclude that the epidemic of listeriosis was caused by ingestion of Brand A cheese contaminated by one phage type of L. monocytogenes serotype 4b.
Article
This article enters the debate concerning comprehensive versus selective primary health care by focussing on UNICEF's 'child survival revolution'. It is argued that UNICEF is dangerously mistaken in believing that its present emphasis on selective primary health care is a precursor or 'leading edge' of comprehensive primary health care. The approach of UNICEF--diffusion of a package of technologies by campaigns organized from the top down--is more likely to undermine the social basis for comprehensive care. The kinds of implementation UNICEF has chosen in order to minimize costs and maximize impact on child mortality, namely 'social marketing' via mass media and massive, ad hoc delivery systems seriously undermine the development of grassroots organization among parents and primary health care workers. Indigenuous, local organizations are distorted and limited to conduits of a delivery system. Needs are defined outside the communities affected. In addition, UNICEF's so-called revolution has in common with other selective approaches an ideology accepting as inevitable the health effects of economic crisis in the 1980s, further undermining the confidence of local groups and health workers who might otherwise conceive of their desire to control health conditions as a right. The UNICEF interventions popularly known as GOBI-FFF are 'targetted' at individuals, in particular 'ignorant' mothers. As such they are especially destructive to the process of group formation and self-organization of the poor around their just demands for water and sanitation, land, shelter, and employment. This article concludes that UNICEF's GOBI should either be abandoned or integrated into comprehensive primary health care programs that put parents and local workers in control and that emphasize continuing political struggle for health rights.
Article
• During September and October 1979,23 patients admitted to hospitals in the Boston area had systemic Listeria monocytogenes infection. Twenty (87%) of these isolates were L monocytogenes type 4b, whereas only nine (33%) of the isolates serotyped during the preceding 26 months had been 4b. Patients with type 4b Listeria infection during the epidemic period (case patients) differed from patients with sporadic Listeria infection in the preceding two years in that more of the case patients had hospital-acquired infection (15/20 vs 4/18), had received antacids or cimetidine before the onset of listeriosis (12/20 vs 3/18), and had gastrointestinal tract symptoms that began at the same time as fever (17/20 vs 4/18). In addition, more case patients took antacids or cimetidine compared with patients matched for age, sex, and date of hospitalization (12/20 vs 10/40). Three foods were preferred by case patients more frequently than by control patients: tuna fish, chicken salad, and cheese. However, the only common feature appeared to be the serving of these foods with raw celery, tomatoes, and lettuce. The raw vegetables may have been contaminated with Listeria, which was able to survive ingestion because of gastric acid neutralization and subsequently to cause enteritis, bacteremia, and meningitis in susceptible hosts. However, we cannot exclude pasteurized milk as a source of this outbreak. (Arch Intern Med 1986;146:520-524)
The Bamako initiative
  • Anonymous
Anonymous. The Bamako initiative [Editorial]. Lancet 1988;ii: 1177-8.
I'he Bamako initiative
  • J Chabot
Chabot J. 'I'he Bamako initiative. Lancet 1988;ii: 1366-7.
A price to pay: the impact of user charges in Ashanti-Akim district
  • C J Vwaddington
  • K A Envimavew
VWaddington CJ, Envimavew KA. A price to pay: the impact of user charges in Ashanti-Akim district, Ghana. InternationalJ7ournal offlealth Planning and Management 1989;4:17-47.