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

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96 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
Specific contracts had no justification if the activity to be carried out was part of the MPS. The agreement and regular reviews were an occasion to examine the reciprocal commitments of each party (Minister of Health and ComHA) and to take into account particularly structural problems. The introduction of the concept of separate contracts for basic activities would have risked taking responsibility from the ComHAs and causing negative effects related to the quest for funds linked to these contracts. Bonuses and benefits. Staff could not be financially motivated using the ComHA as the driving force without calling into question the principles of decentralization and community participation. Some ComHAs negotiated bonuses, whereas others helped with housing arrangements; the community traditionally gives money to staff who come to the village to perform services. But these initiatives do not constitute an adequate response to a problem that is becoming increasingly serious. Medicalization of the first level. Recruiting a temporary doctor costs significantly more for a ComHA than recruiting a nurse. Sooner or later, however, the urban first level will be medicalized, and in the foreseeable future, some of the relatively rich rural areas will also inevitably host a number of doctors in training. On the other hand, to be appointed by a ComHA is not often the first choice for a doctor or even for a nurse. Indeed, the rural ComHCs encountered difficulties in recruiting nurses, who prefer the informal prosperous sector in the cities and towns while waiting for eventual recruitment to public service. In some cases a ComHC failed to launch because a nurse could not be found. 81 The urban ComHCs are not always able to retain their doctors, who also would rather be employed by the public service, even if the pay is two times lower, or working for an NGO. The public sector’s commitment to assure the availability of the required number of doctors per district (three to five doctors per district) is far from being met. The constraint of the structural adjustment programme in recruiting staff in the health and education sectors remains a reality. 82 It may be a long time before doctors rush to the rural ComHCs seeking employment. de la Solidarité et des Personnes Agées. 81 Mali does not produce enough nurses to satisfy the plan for extended coverage. Centralized training for middle level managers in Bamako does not favour allocating them to rural regions. 82 Even thought devaluation of the FCFA helped to alleviate it. Studies in HSO&P,20,2003 97
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Studies in Health Services Organisa
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Acknowledgements The authors partic
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Limits of past experiences A new he
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purchase drugs from the dispensarie
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workshops and specialized studies b
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Community participation in managing
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decentralization, and integration o
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esearchers were often involved in d
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Achievements and problems Declarati
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1990-1992: towards a strategy for c
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technical assistants who were exper
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making all the right decisions at t
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plans started with a discussion of
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extending coverage. Initially, each
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the district, and to assess what hu
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of the area. • Guarantees a minim
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Health (to such an extent that some
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THE ISSUE OF ESSENTIAL DRUGS From i
Page 39 and 40:
The new strategies were developed w
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That may appear simple and obvious,
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managerial instrument tools for fol
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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
Page 73 and 74: % Expected births Figure 12. Obstet
Page 75 and 76: ambulance evacuation by the health
Page 77 and 78: The ComHA-BA—the community health
Page 79 and 80: maintaining the centre’s capacity
Page 81 and 82: 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
Page 87 and 88: financing of the ComHCs was conside
Page 89 and 90: to placing the complex and costly r
Page 91 and 92: Profit on drugs. Another aspect tes
Page 93 and 94: These simulations deliberately favo
Page 95 and 96: Table 20. Distribution of investmen
Page 97 and 98: Results for the first ComHCs projec
Page 99: The answers to these questions emer
Page 103 and 104: 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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