Health sector reform in Mali, 1989-1996 - TropMed Central Antwerp ...

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6 Region and in Bamako District following careful consideration by the Ministry of Health regarding the respective roles of the State and the community. Towards the end of the 1980s, several projects 5 launched costrecovery experiments designed to ensure the availability of essential generic drugs. These experiments showed that people were ready to pay for betterquality service. The payments significantly contributed to the good functioning of services provided, and often allowed recruitment of additional qualified staff. For example, Djenne District succeeded in financing 44% of its operating costs from its own revenue. 6 Moreover, substantial effort was made within the framework of the HDP to organize care effectively in a health centre. 7 Starting from the premise that the principle of free care had had its day, these trials and initiatives highlighted the importance of the community in creating and managing health centres. The efforts were particularly significant considering that the country was undergoing structural adjustment. In Mopti, the Regional Health Directorate succeeded in coordinating health development partners (Médecins du Monde, UNICEF, and the Deutsche Gesellschaft für Technische Zusammenarbeit) to put in place an essential drugs supply system with cost recovery. 8 From 1987, a series of 5 Berche T & Mariko M (1991) Le financement des couts recurrents de la santé dans le cercle de Bandiagara; analyse économique et santé publique. Report. 112p. Bamako: Institute National de Recherche en Santé Publique. Cisse S (1993) Analyse d’une expérience d’approvisionnement en médicaments essentiels au Mali. Projet “magasins santé”. Report. Brussels: Ecole de Santé Publique. 148p. Kegels G (1994) Paying for health instead of buying drugs: an experience from Western Mali. Annales de la Société belge de Médecine Tropicale 74, 149-160. Mariko M (1990) Diagnostic du système de recouvrement des couts de la region de Koulikoro. Report. 98p. Bamako. Diarra K & Robez-Masson D (1992) Le financement des couts recurrents de la santé dans le cercle de Djenne au Mali. Initiative de Bamako. Technical Report No. 14. 34p. New York: UNICEF. 6 Diarra K & Robez-Masson D (1992) Le financement des couts recurrents de la santé dans le cercle de Djenne au Mali. Initiative de Bamako. Technical Report No. 14. 34p. New York: UNICEF. 7 World Bank (1991) Rapport d’évaluation du Projet Santé, Population et Hydraulique Rurale, République du Mali. Report. 204p. Washington: World Bank. Kegels G (1994) Paying for health instead of buying drugs: an experience from western Mali. Annales de la Société belge de Médecine Tropicale 74, 149-160. Konate S (1993) Réflexions sur la santé au Mali: réalités, problématique et perspectives. 150p. Bamako. 8 Ministère de la Santé et des Affaires Sociales (1990) Système de gestion des services de Studies in HSO&P,20,2003
workshops and specialized studies built on past experience to prepare new national orientations for health programmes and projects being planned with the principal partners of the sector (World Bank, UNICEF, USAID, and the Coopération Française). These activities helped to develop a convergence of views among an about-to-be critical mass of national health professionals. Under the direction of an ad hoc group comprising key officials from the Ministry, and with the participation of health professionals at all levels (nationals and expatriates working in Mali), the Bamako Initiative was finalized in August 1989. 9 It integrates and formulates the principles of health sector organization and development. Decentralization (with a new definition of roles at each level) and genuine community responsibility for managing health centres (storage of drugs in particular) were accorded the same importance as availability of essential drugs. A new national policy Presentation of the Bamako Initiative to the Council of Ministers at the end of 1989 testified to the extent and political importance of the changes envisaged. It was in this context that formulation or reformulation of programmes among partners such as the World Bank, UNICEF, USAID, and the European Development Fund (EDF) could be coordinated, notably, during joint World Bank-UNICEF evaluation missions. Finally, through the Health, Population, and Rural Water Project, or HPRWP, the principle of cofinancing and complementary support was retained as the vehicle for motivating and implementing the new health sector policy. 10 The term project did not reflect the scale of change. However, basically for legal reasons, the World Bank was constrained to use the term at the time. This process led to framing of a national health policy—solemnly declared by the government—that went far beyond statements of intent and reaffirmation of principles. 11 The policy was based on elements defined by santé a partir de l’expérience de la région de Mopti: document de travail. 18p. Bamako: Ministère de la Santé et des Affaires Sociales. 9 Ministère de la Santé et des Affaires Sociales (1989) Plan de relance des SSP. Initiative de Bamako: cadre conceptuel. 39p. Bamako: Ministère de la Santé et des Affaires Sociales. 10 World Bank (1991) Rapport d’évaluation du Projet Santé, Population et Hydraulique Rurale, République du Mali. Report. 204p. Washington: World Bank. 11 Ministère de la Santé, de la Solidarité et des Personnes Agées (1990) Déclaration de Studies in HSO&P,20,2003 7
Page 2 and 3: Studies in Health Services Organisa
Page 5 and 6: Acknowledgements The authors partic
Page 7 and 8: Limits of past experiences A new he
Page 9: purchase drugs from the dispensarie
Page 13 and 14: Community participation in managing
Page 15 and 16: decentralization, and integration o
Page 17 and 18: esearchers were often involved in d
Page 19 and 20: Achievements and problems Declarati
Page 21 and 22: 1990-1992: towards a strategy for c
Page 23 and 24: technical assistants who were exper
Page 25 and 26: making all the right decisions at t
Page 27 and 28: plans started with a discussion of
Page 29 and 30: extending coverage. Initially, each
Page 31 and 32: the district, and to assess what hu
Page 33 and 34: of the area. • Guarantees a minim
Page 35 and 36: Health (to such an extent that some
Page 37 and 38: THE ISSUE OF ESSENTIAL DRUGS From i
Page 39 and 40: The new strategies were developed w
Page 41 and 42: That may appear simple and obvious,
Page 43 and 44: managerial instrument tools for fol
Page 45 and 46: operational forms to facilitate int
Page 47 and 48: that were largely committed did not
Page 49 and 50: Table 9: Achievements and problems
Page 51 and 52: 1993-1995: first achievements Distr
Page 53 and 54: Methods workshop 2 weeks Finalizing
Page 55 and 56: evaluation of the approaches was po
Page 57 and 58: approach through negotiations, with
Page 59 and 60: Figure 9. Performance in the health
Page 61 and 62:
In Dougouolo, a survey 45 revealed
Page 63 and 64:
REACTION Establishing the MPS with
Page 65 and 66:
transformed into a ComHC? Should th
Page 67 and 68:
contributed to the debate at the na
Page 69 and 70:
Organizing and developing referral
Page 71 and 72:
on these experiments, but in both s
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% Expected births Figure 12. Obstet
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ambulance evacuation by the health
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The ComHA-BA—the community health
Page 79 and 80:
maintaining the centre’s capacity
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Table 15. Effects of contractual mo
Page 83 and 84:
Motivation of health staff received
Page 85 and 86:
Financing of the sector and viabili
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financing of the ComHCs was conside
Page 89 and 90:
to placing the complex and costly r
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Profit on drugs. Another aspect tes
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These simulations deliberately favo
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Table 20. Distribution of investmen
Page 97 and 98:
Results for the first ComHCs projec
Page 99 and 100:
The answers to these questions emer
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Specific contracts had no justifica
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etter still, to do it in a way that
Page 105 and 106:
Table 22. Operating account for23 C
Page 107 and 108:
1995. Even though begun, this evolu
Page 109 and 110:
1994-1995: Scaling up and improving
Page 111 and 112:
implementations and their acceptabi
Page 113 and 114:
Extension of coverage had to be acc
Page 115 and 116:
priority was always given to the se
Page 117 and 118:
When achievements started to mount
Page 119 and 120:
Faced with increasing pressure, tec
Page 121 and 122:
Figure 24. Performance achieved in
Page 123 and 124:
SDHC; on the right, the area that b
Page 125 and 126:
situation opened prospects for inte
Page 127 and 128:
Managing change Without the project
Page 129 and 130:
Figure 27. The position of national
Page 131 and 132:
commitment score 5 4 3 2 1 0 -1 -2
Page 133 and 134:
Joint central supervision 104 playe
Page 135 and 136:
Table of contents Acknowledgements
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Health sector reform in Mali, 1989-1996 - TropMed Central Antwerp ...

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