(Written by Bruno Meessen on behalf of the Harmonization for Health in Africa communities of practice)

25 years ago, between the 3rd and the 7th of August 1987, the WHO organized an interregional meeting in Harare. The meeting, which was about the implementation of primary health care (following up of the Alma Ata conference in1978), ended with a statement that is known (or forgotten!) today as the Harare Declaration. By establishing the health district model as a reference strategy to organize and develop health services, this event shaped health systems in many poor countries. This strategy particularly shaped health service provision in rural Africa.

A few weeks later, UNICEF organized another regional meeting in Bamako. It went down in history as the Bamako Initiative. Its content is better known: it marked the introduction (or formalization) of user fees and that of community participation in resource management, including essential drugs now sold to users.

Like the vast majority of policies, these proposals were based on pilot experiments or similar approaches already in place in some countries, for example, the “health shops” of Mali (cost recovery) or the experience of health zones in Zaire (health district strategy).

25 years have passed. Globalization and new information technologies have profoundly changed the environment. The structural adjustments of the 80s are long gone. Today the African continent is experiencing the strongest economic growth. Some countries have been able to exploit this new phenomenon for major changes in their health system and its financing. Rwanda has shown that the goal of universal coverage is not insane. But the continent is far from being homogeneous. HIV / AIDS is ravaging southern Africa. For the Horn of Africa to Central Africa and a fraction of West Africa, these 25 years have been plagued by armed conflicts. These shocks, coupled with the effects of the global economic crisis of the 80s, have been particularly harmful to health care systems. Many would argue that the potions that were administered to patients (structural adjustment programs, privatization, introduction of user charges…) have not helped, moreover, had long-term side-effects on health systems.

In the coming months, several communities of practice affiliated with “Harmonization for Health in Africa” (in 25 years, agencies have also realized the need to coordinate better!) will collaborate to develop a collective reflection on the Harare Declaration and Bamako Initiative. Several organizations have already indicated their willingness to be partners in this endeavor. Like us, they believe that the issues identified in Harare and Bamako 25 years ago are still valid, although some updating is required.

We hope that this process will lead to both face-to-face events and online discussions.

We are already happy to announce that the Health Financing in Africa blog will host various contributions by international experts. These experts will reflect on the past, assess the present and develop a vision for the future. They will be provocative or try to contribute to synthesis. They will bridge generations of experts and different continents. They will share the most recent knowledge on topics such as user fees, health service organization and community participation. They will be scholars, policy makers or practitioners. They will be from Africa and the other continents.

Hopefully, they will contribute to fairer and more efficient health systems in low-income countries, particularly in Africa.

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