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

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98 What are the solutions for the non-viable areas? With barely 30% of the population living within 5 km of a health centre (stable proportion for more than 15 years), it was not reasonable to expect total coverage in fewer than five years. So it made sense to give priority to the areas which appeared structurally viable at the outset. Revitalization of SDHCs would change the accessibility and quality of care in Mali in the coming years. By the year 2000, more than 45% of the population lived within 5 km of a health centre offering a MPS and managed by the community. It is time to evaluate the areas that this initial effort contributed to changing to better assess implications, mobilize resources (financial and human), and use those resources to organize solidarity at all levels to assure the establishment of ComHCs in areas not yet covered. According to available health maps at the central level in December 1995, out of a total of 614 health areas comprising 6,350,000 inhabitants, 425 were programmed by the year 2000. They included 4,675,000 inhabitants and represented 74% of projected health areas. The number of programmed areas containing fewer than 7,500 inhabitants was 133 (31%). Out of the 189 areas not yet programmed, 104, or 55%, had fewer than 7,500 inhabitants. These numbers imply the use of financial viability criteria in the programming, but they also suggest that these criteria are not absolute. Other criteria were taken into account locally, including the commitment and determination of communities in the area. Devaluation THREATS TO REFORM On 12 January 1994 the FCFA was devaluated by 50%. It was clear that this event could compromise implementation of the health sector policy and reduce the viability of the ComHCs. Should priorities in the health sector be reconsidered in light of devaluation, or should reform be pursued? Should drugs be subsidized? How could generic drugs be made available to the whole population? What would the effect of devaluation be on the frequency of services and on their viability? The response to devaluation—virtually unanimous, though with some hesitation—was to accelerate implementation of the new policy and, Studies in HSO&P,20,2003
etter still, to do it in a way that the accompanying measures strengthened rather than weakened it. The main problem was drugs. 83 The implication for the selling price of drugs was that devaluation would lead to a price increase of more than 60%. This would have put drugs out of reach for a significant segment of the population. There was a strong temptation to insulate provision of drugs to health centres from the process of on-going technical and community management, or at least, to subsidize the drugs. At the time, there were no more than 10 centres using generic drugs. For most of the Malian population, improving the availability of generic drugs was a better solution than subsidizing them. Subsidies nevertheless proved useful to avoid diluting the capital of existing drug depots, given that the government had decided to freeze selling prices. Finally, the Canadian government granted Mali FCFA 1 billion through the PPM. 84 The funds were used to stabilize the sale price of 15 essential drugs for one year and to supply private dispensaries under favourable conditions. These measures were very controversial. They did not prevent dilution of capital at the peripheral health centres, nor did they resolve the problem of availability of essential drugs. The contract between the State and the PPM never met expectations. Massive subsidies had allowed the PPM to order considerable quantities of generic drugs (more than FCFA 2 billion). The availability of these drugs in the regions was overwhelming. It was possible to conclude that the ComHCs would never lack drugs in the future. But the problem of sustaining the supply remained. The market was very far from being saturated despite devaluation. VIABILITY OF ACCESS After an initial dilution of capital, the ComHCs reflected the effect of devaluation in the sale price of drugs. In contrast, fees for consultations did not change. There was no drop in attendance, but notably, the number of 83 Ministère de la Santé, de la Solidarité et des Personnes Agées (1994) Assurer la disponibilité du médicament essentiel au prix le plus bas après la dévaluation. Rapport du groupe de travail constitué le 4 Mars 1994. 69p. Bamako: Ministère de la Santé, de la Solidarité et des Personnes Agées. 84 Gouvernements de la République du Mali et du Canada (1994) Protocole d’entente concernant la livraison de médicaments essentiels. Bamako: Gouvernments de la République du Mali et du Canada. Studies in HSO&P,20,2003 99
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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
Page 45 and 46:
operational forms to facilitate int
Page 47 and 48:
that were largely committed did not
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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 and 100: The answers to these questions emer
Page 101: Specific contracts had no justifica
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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