Press centre

Speeches

The Bamako Initiative

Bamako, Mali, 8 March 1999

Your Excellency, Mr. President; Your Excellency, Mr. Prime Minister; = Your=20 Excellency, Madame Minister of Health, Aged People and Solidarity; the = Regional=20 Director of WHO; Your Excellencies, the Ministers; Your Excellencies, = members of=20 the diplomatic corps and representatives of international agencies; = honourable=20 guests:

It is with enormous pleasure that I have accepted on behalf of UNICEF = the=20 invitation made by the Government of Mali to speak to this illustrious=20 gathering.

Mr. President, development is, by definition, a long-term = undertaking. And by=20 that measure, the nearly 12 years that have passed since the Bamako = Initiative=20 was first embraced by African Health Ministers have been equivalent to = the blink=20 of an eye. Yet the split-second of development history that began in = 1987 has=20 already made a profound difference to the lives of millions of children = and=20 women =96 not only here in Africa, but around the world. And it = continues to make=20 a difference to this day.

Thanks to the process that was launched in Bamako with the World = Health=20 Organization (WHO) and UNICEF, the world has seen significant reductions = in=20 maternal and child mortality =96 reductions that have brought us closer = to our=20 goal of assuring every child a better future.

Mr. President, the Bamako Initiative is a testament to the hard work = and=20 solidarity of untold numbers of dedicated people on the ground =96 many = of you=20 here, at this important conference =96 who understood from the very = beginning that=20 the key to accessible and affordable health care for all lies in the = informed=20 involvement of local communities.

Indeed, since the Initiative was adopted, we have seen abundant = evidence that=20 communities possess not only the motivation, but the capacity, to = participate in=20 the management of their own health care services.

Thanks to the Bamako Initiative, improved and sustained immunisation = coverage=20 and other preventive activities have grown as governments have increased = their=20 capacity to provide essential drugs and vaccines.

Even in countries facing severe economic distress, the Bamako = Initiative has=20 ensured that revitalised basic health care facilities have been able to = offer a=20 variety of services, including provision of essential drugs.

The recently introduced Health Sector Reforms =96 which in some = countries were=20 preceded by the Bamako Initiative =96 have sought to accelerate the move = toward=20 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 =96=20 they have empowered individuals and families to assume responsibility = for their=20 own health and welfare. And it is in that sense, Mr. President, that the = Bamako=20 Initiative has been a major step toward democratising the business of = primary=20 health care.

The success of the Bamako Initiative can be traced directly to three = major=20 factors: the willingness of leaders at all levels of the health sector = to be=20 innovative, to take risks, and to be effective communicators; the solid=20 technical excellence that can be found even in small-scale projects =96 = and the=20 flexibility of the Initiative itself, which, instead of fixed, top-down=20 measures, offers a set of strategies for revitalising health services = that can=20 be adapted to a wide variety of situations and cultural contexts.

All told, some 35 countries have implemented the eight basic = principles of=20 the Bamako Initiative for use in nationwide programmes =96 programmes = that involve=20 such major components as immunisation, vitamin A supplementation, safe=20 motherhood, guinea-worm eradication and community participation = activities.

In Africa alone, the Bamako Initiative has helped ensure access to = affordable=20 and sustainable primary health services for more than 60 million people = through=20 the revitalisation of 6,000 health centres =96 managed and partially = funded by=20 local communities or districts in countries like Cameroon, the Gambia, = Mali,=20 Mauritania, Niger, Nigeria, and Togo.

In West Africa, some 30 per cent of all health centres in 15 nations = have=20 been revitalised. Indeed, some countries, like Benin, Guinea and = Senegal, have=20 succeeded in strengthening virtually all of their public primary health = centres=20 with additional help from the World Bank and bilateral partners.

But as we approach the millennium, Mr. President, enormous challenges = remain.=20

A decade of gains in child survival are being reversed by the = terrible=20 effects of the HIV/AIDS pandemic, combined with the continuing scourges = of=20 malaria and malnutrition and micronutrient deficiencies, among others. =

At the same time, deteriorating economic conditions and civil strife = in many=20 countries have disrupted long-term planning and provision of health = services.=20

Furthermore, accessibility to basic health services remains a major = problem=20 in sub-Saharan Africa and parts of Asia. In numerous places, the = majority of=20 people still live more than five kilometers away from the nearest health = center.=20

Quality of care has also lagged behind the increase in coverage, = often=20 contributing to the under-utilization of services and slowing efforts to = reach=20 the health and nutrition goals of the World Summit for Children.

Because of the Bamako Initiative, we know that the decentralization = of=20 government to a sub-national level can help promote intersectoral health = interventions while empowering communities. But there is a potential = downside:=20 decentralisation can also complicate the implementation of a coherent = national=20 health policy because of conflicting local interests.

Preventive care also tends to suffer because curative and = hospital-based care=20 is more visible and often reaps more financial and political benefits.=20 Decentralisation must be accompanied by measures to ensure that the = technical=20 and logistical support previously provided by traditional =93vertical = programmes=94=20 is made available to health teams in the decentralised entities.

Mr. President, this review of the implementation of the Bamako = Initiative is=20 a moment to take stock of how far we have come =96 and to assess what = steps we=20 must take to build on past achievements. Let me suggest a few:

We must ensure that the decentralisation of responsibility for health = care=20 management is matched by enhanced resource allocation and = decision-making at=20 local levels.

Sector Wide Approaches, which have been promoted in several of the = countries=20 implementing the Bamako Initiative, could bring about more consistent = government=20 leadership, improved donor coordination and more efficient use of = resources,=20 including at decentralised levels.

However, since these approaches involve such a wide range of sectoral = issues,=20 we must guard against a tendency to increase administrative burdens in = programme=20 planning and implementation =96 causing a corresponding decrease in the=20 involvement of communities and the civil society. There is also a risk = that=20 intersectoral collaboration for solving health problems will decline, = depriving=20 programmes of flexibility and capacity to innovate.

Mr. President, these are all daunting problems =96 and the strategies = and=20 recommendations that emerge from this conference must address them if we = are to=20 ensure the protection of children=92s rights, help meet their basic = needs =96 and=20 expand their opportunities to fully develop and participate.

You must draw on past lessons, but do so within the context of = rapidly=20 changing global and local conditions and declining financial and human = resources=20 =96 including the continuing plunge in Official Development Assistance, = a=20 situation that has put the lives of millions of children and women at = risk.

Excellencies, Distinguished Delegates: Over the next five days, I = would=20 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=20 essential health care. This implies adapting existing strategies to = ensure that=20 the most marginalised and difficult-to-reach populations have access to = quality=20 health care. Specific strategies may include additional outreach = capacity, use=20 of national child days, strengthening of referral care and alliances. = Specific=20 strategies will need to differ =96 some must address the needs of = scattered=20 populations or the urban poor, while others, such as in Asia, must be = designed=20 to take account of the enormous number of beneficiaries who must be = reached.=20 Health sector reforms represent a new opportunity to advocate for the=20 responsibility of governments to assure access for all to the basic = package of=20 essential care, regardless of who actually provides that package. =
Second, we=20 must strengthen and broaden partnerships for health. To assure universal = coverage with a minimum package, other service providers should be = included from=20 the start: the private sector, non-governmental organisations (NGOs) and = schools, for example =96 and partnerships must be promoted between them = and=20 communities at the local, district and national levels. Civil society,=20 especially through women's and youth groups, must also be involved as = co-actors,=20 and in governance at the local level. The expansion of partnerships must = also=20 take into account the cost of services and local capacity to pay. We = cannot=20 expect the world=92s poorest citizens to be wholly responsible for = health care=20 that, in more fortunate areas of the world, is covered by insurance, = subsidies=20 and grants. We must find creative avenues to ensure that all partners, = including=20 governments and the international community, make good on their = obligations to=20 guarantee the right to health services for all.
Third, the minimum = package=20 of health activities must be adapted to include strategies to control = new and=20 re-emerging problems and take advantage of recent technological = advances, using=20 the opportunity of global initiatives and approaches. This includes = prevention=20 of mother-to-child transmission of HIV as well as sexually transmitted = diseases=20 (STDs); the Roll Back Malaria effort; the eradication of polio; better = control=20 of vaccine-preventable diseases, and the Integrated Management of = Childhood=20 Illness (IMCI), as well as maternal and neonatal mortality reduction and = adolescent health.
Finally, more emphasis must be placed on = empowering women=20 and young people to promote their own well-being and to acquire basic=20 life-skills. This can be achieved by strengthening self-care practices = and=20 household care of children. In this way, women and young people can play = a more=20 effective role in improving their own health and the health of their = community.=20
Mr. President, let me remark, in closing, on a particularly pleasing = piece=20 of historical symmetry: the fact that this meeting has convened on the = same day=20 that the world is observing the last International Women=92s Day of the = 20th=20 Century.

It is therefore a doubly appropriate occasion to reflect on the = progress made=20 in the struggle for equal rights for women, and on the need to ensure = their full=20 participation in the development process.

Women have been key to the success of the Bamako Initiative to date, = both as=20 beneficiaries and as contributors to health initiatives.

Yet as the Secretary-General points out in his Women=92s Day message, = =93gender=20 equality, to which we have so long aspired, is still far from = reality.=94 And as a=20 result, women and girls continue to pay with their lives for inadequate=20 provision of health care.

Mr. President, it is clear that one of the key challenges to = effective health=20 care remains the full participation of women. In many countries, they = are still=20 marginal actors in health care delivery, both in numbers =96 and = especially in=20 decision-making.

Even in their own households, women often lack the power to make = decisions=20 relevant to the health of their children, not to mention their own.

Where women are excluded, health systems cannot adequately address = women=92s=20 needs. There are a variety of reasons for this, many of them external to = the=20 health sector: culture and tradition, financial constraints and = illiteracy,=20 among others. All of them add up to discrimination.

The health of society cannot be assured unless women=92s rights to = equality and=20 full participation are assured =96 and it is essential that health = programmes=20 recognize and fully address that fact.

Mr. President, UNICEF's commitment to the realization of children=92s = rights,=20 as set out in the Convention on the Rights of the Child, is why UNICEF = spends=20 one third of its total funds on programmes aimed at improving child = health.=20 UNICEF's commitment =96 and the commitment of its partners, who include = so many of=20 you here today =96 are major reasons why the lives of more than 2 = million young=20 children a year are now being saved through a combination of prevention = and=20 primary care.

These commitments and these partnerships are why the eradication of=20 poliomyelitis and guinea-worm disease is imminent, with measles soon to = follow.=20

They are why the nutritional benefits of mothers breastfeeding their = infants=20 is beyond dispute, and why the unethical promotion and distribution of=20 breastmilk substitutes has been significantly reduced.

These and other encouraging developments documented by the=20 Secretary-General=92s Mid-Decade Review of Progress for Children show = how far we=20 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=20 the overall health of children and women over the last 20 years, the = health=20 challenges we face are growing ever more complex and daunting. And as I = noted,=20 this is happening at a time when health and development assistance to = developing=20 countries continues to decline.

Distinguished Delegates, UNICEF will redouble its efforts to work = with you=20 and other partners to ensure the right of every child and every woman to = quality=20 essential health care. And it is vital that this important Conference = come up=20 with measures that will ensure that the Bamako Initiative fulfils its = historic=20 promise.

Thank you.

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