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

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100 unused prescriptions increased. 85 The financial situation improved following the increase in sale prices, but to the detriment of affordability for the population. Viability thus prevailed over affordability. 86 In 1995, the year following devaluation, only 3 out of 39 health centres for which detailed operational accounts were available showed deficits (depreciation of the refrigerator and medical equipment being the responsibility of the State) (Table 22). Most of the ComHCs were established after devaluation and had not faced the same risk of dilution of capital for their drug depots. These centres continued to offer well-regarded services with balanced accounts, indeed, surpluses. They were able to cover all local operating costs (including petrol for the cold chain and fuel for logistics). The cost of services had certainly increased in the old centres (in particular in the region of Mopti). But the new centres (the majority) constituted a new opportunity and important progress for a population devoid of easy access to care services and which, in emergencies, had to pay a fortune to obtain brand-name drugs. 85 This phenomenon is especially notable in Mopti Region, where implementation of the new health policy included assuring continuity of a system for distributing essential drugs already in place through a regional project. This system had been destabilized by the devaluation, but also by restocking in PPM stores. When they were available, the generic drugs were clearly more expensive than those of the former round of stocking under the project, or even those of the GIE Santé pour Tous. In Mopti, the average cost of prescriptions was more than FCFA 1,200, as opposed to FCFA 700 in other regions. One patient in five could not afford to buy the drugs prescribed to them. See Berche T & Mariko M (1991) Le financement des coûts recurrents de la santé dans le cercle de Bandiagara; analyse économique et santé publique. Report. 112p. Bamako: Institut National de Recherche en Santé Publique. Oepen C, Coulibaly F & Neuhaus E (1997) Combien pourraient coûter des soins de qualité. In: Brunet-Jailly E (ed) Innover dans les systèmes de santé. Expériences d’Afrique de l’Ouest, 257-270. Paris: Editions Karthala. Diarra K & Robez-Masson D (1992) Le financement des coûts recurrents de la santé dans le cercle de Djenne au Mali. Initiative de Bamako. Technical Report No. 14 34p. New York: UNICEF. 86 Direction Nationale de la Santé Publique (1993-1996) Série 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 techniqes et de rapports de supervision des centres de santé de cercle et CSCom/CSAR. Bamako: Ministère de la Santé, de la Solidarité et des Personnes Agées. UNICEF-Mali (1989-1996) Série de rapports de revues annuelles et à mi-parcours et notes techniques. Bamako: UNICEF. Studies in HSO&P,20,2003
Table 22. Operating account for23 ComHCs and 16 R-SDHCs the year following devaluation ComHC R-SDHC Surplus Balanced Deficit Surplus Balanced Deficit Kayes 1 5 1 0 1 0 Koulikoro 1 2 1 2 1 0 Ségou 5 3 1 4 1 0 Mopti 1 1 0 7 0 0 Sikasso 1 0 0 0 0 0 Total 9 11 3 13 3 0 SOURCE: S. Samake, F. Giudetti, and A. El Abassi. Note: The R-SDHCs have a nurse paid by the State; the ComHCs pay the nurse’s salary themselves. A price increase of FCFA 50 would have significantly improved the account’s chances of remaining balanced (Fig. 20). But it would have reduced affordability and assumed elasticity of demand. In truth, the major consequences of devaluation are still to come, and concern depreciation of equipment (practically all imported) and logistics. Paying back a fuel refrigerator costing close to US$ 2,000 and a motorcycle costing US$1,000 became difficult for the rural health centres, even though some had hoped to do so at the start. For the ComHCs to be able to cover depreciations would have required a level of attendance much higher than 0.35 (Fig. 20). The rates of attendance observed before devaluation ranged between 0.15 and 0.25 in the ComHCs and R-SDHCs; elsewhere. it was often less than 0.10. It is unthinkable that the ComHCs, in particular the rural ones, can survive and respond to the demands on them without the State guaranteeing (with the support of external partners) depreciation of equipment or contributing to logistics. After devaluation this commitment from the State was inevitable. It was necessary to act very quickly to avoid bottlenecks when the time came for replacement. Studies in HSO&P,20,2003 101
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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
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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
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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 and 102: Specific contracts had no justifica
Page 103: etter still, to do it in a way that
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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