The Bamako Initiative was launched in 1988 by UNICEF to revitalize the public sector health care delivery system by strengthening district management and capturing some of the resources the people themselves are spending on health. Eighteen African countries were participating as of late 1991 and nearly 1,800 health centres located in 221 districts were part of the programme. In Benin the first 44 health centres targeted by the initiative are covering between 40 and 50% half of their operating costs with user charges, as are the first 17 centres in Guinea's programme. In Benin average monthly visits to pilot health centres rose from 100 in 1987 to 250 in 1989.The Bamako Initiative is based on two premises: (1) That where public institutions are weak, as they are in many low-income countries, bottom-up action by communities is badly needed to complement top-down health policy reforms, and (2) That even poor households are willing to pay for higher-quality and more reliable health services. Under the initiative, members of local communities who use a health centre of pharmacy agree to pay modest charges for outpatient care, including drugs. The revenues generated from fees are retained by the health centres and managed by local elected committee. The committees reinvest in additional drugs (through a revolving fund), in incentive payments for health workers, and in other improvements. The government and donors assist health centres in purchasing inexpensive generic drugs, thus increasing the cost-effectiveness of services at the health centre. Problems may emerge when external assistance ends, particularly in converting local revenues generated through user charges into the foreign exchange needed to purchase imported drugs.