Strengthening health services for MCH in Africa: the first four years of the ‘Bamako Initiative’

More than four years have passed since the adoption of the ‘Bamako Initiative’ by African Ministers of Health. It has evolved into a movement to revive and extend peripheral health services within a districtlevel strengthening of health care delivery systems, placing responsibility for health care management at the local level, but with continuing national Ministry of Health (MOH) technical supervision and support. This will provide the basis on which prime mother and child health care interventions, such as immunization, prevention and control of common diseases and pre- and postnatal care, can be made accessible to the majority of the population, and on which HIV/AIDS-related action can be accelerated. Community action in the management and financing of peripheral health services is seen as the most critical element for improving service quality and ensuring long-term sustainability. Whilst many countries in Africa have initiated action, difficult issues remain: access for the very poor who cannot afford to pay; the rational use of drugs given a more continuous supply of essential drugs in the delivery system; the ability of govern ments to maintain their support in the face of declining economies; and the role of women in community action.