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

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needed to increase access for the poor. Each dimension requires action, but
they should not be confused.
Itinerant services. Depreciation of the refrigerator, and shipment and
supply of vaccines made up nearly 90% of the actual costs of vaccination
and itinerant services. The State covered these costs and seemed ready to
meet the total or partial cost of depreciation of the motorcycle. The local
costs of the forward strategy were of the order of FCFA 160,000 per year for
maintenance and fuel (US$ 320 at the average exchange rate for 1995), and
FCFA 90,000 per year (US$ 180) for fuel for the refrigerators. That
represents less than FCFA 20 per inhabitant per year and hardly more than
3-4% of the total operational cost of the health centre. It is obviously
modest with regard to a budget of more than FCFA 6 million. The
advantage of having the ComHCs bear the local costs is that the health
centre has greater autonomy vis-à-vis inputs available in all the regions, and
in local and community control of these expenditures. An example is the R-
SDHC of Touna, where the nurse had to stop vaccination services for one
month. The programme had failed to supply petrol, despite the fact that the
centre funds were adequate, petrol was available, and the village and
committee were perfectly capable of assuring continuity of vaccinations.
The rural ComHAs place great importance on itinerant services
(which are not limited to vaccinations, but do not include curative care),
and they ensure that the nurse performs them in accordance with the
schedule fixed through microplanning. It is a solution of sorts to equalizing
access to the health centre and of strengthening the solidarity of the group
of villages around their centre. This involvement would be meaningless if
the financing of local costs remained under the responsibility of vertical
programmes, for the health staff would not be accountable to the
community. Some ComHAs have even organized annual renewable
contributions to guarantee these services; others have recommended that
three sessions per week be devoted to itinerant activities at the risk of
affecting the continuity of curative care in the health centre. 80
80 Direction Nationale de la Santé Publique (1993-1996) Serie de rapports de missions
centrales conjointes (DNSP - PSPHR - UNICEF - Partenaires) de supervision des
CSCom/CSA dans les régions. Bamako: Direction Nationale de la Santé Publique -
Ministère de la Santé, de la Solidarité et des Personnes Agées. Directions Régionales de la
Santé et de l’Action Sociale de Bamako, Mopti, Ségou, Kayes, Sikasso, Koulikoro, Mali
(1993-1996) Etat d’avancement, études de cas, séries de notes techniques et de rapports de
supervision des centres de santé de cercle et CSCom/CSAR. Bamako: Ministère de la Santé,
Studies in HSO&P,20,2003