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

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102 Figure 20. Depreciation and devaluation: effects on the financial equilibrium of a rural ComHC FCFA 500.000 400.000 300.000 200.000 100.000 -100.000 -200.000 -300.000 -400.000 -500.000 Studies in HSO&P,20,2003 0 10% 15% 20% 25% 30% 35% Usage rate Before devaluation Depreciation 1 Depreciation 2 Depreciation 2 + FCFA 50 Note: ComHC with a population of 9,631 inhabitants of which 55% live within 5 km of the health centre. Depreciation accruing to ComHC: Depreciation 1 = refrigerator over five years, small tools over three years, mobilette over three years. Depreciation 2 = small tools over three years, mobilette over three years. Option = rate increase of FCFA 50. Financing the district health system In the districts where a cost-recovery system was organized, close to 50% of the operating budget came from local revenue, with the State continuing to pay salaries. The non-functional health areas were and remain covered by the SDHCs, at least for preventive care. For this the R-SDHC receives a modest subsidy. In the framework of the new programme, the State needed to increase the health portion of the State budget from 4% in 1991 to 9% in
1995. Even though begun, this evolution remained short of objectives (6.56% in 1996) (Fig. 14). The increase was aimed at improving the basic functioning of the system and in particular that of referral. The problem at this level is more fluidity and flexibility in mobilizing resources at the decentralized level. It was not rare to observe that in the third quarter, the health budget showed a significant delay in execution, though the needs were far from being covered. Here, the problem was one of structuring and effective decentralization of budgets. In many countries the Ministries of Finance do not always look favourably on decentralization. And staff responsible for finance are not easily inclined to modify procedures and material. Nevertheless, a solution is needed so that referral centres and the district management team can respond to programme demands with budgetary resources sufficient to guarantee basic operations. Otherwise, users will have to pay high prices for each hospitalization or surgical intervention, especially since there is still no solidarity mechanism to take care of referral cases, other than a few promising projects. An evaluation of the costs and financing of the district health system was undertaken in 1996. 87 It covered three districts and one Bamako commune. The operational costs, less depreciation, of the first referral varied from FCFA 530 per inhabitant for Commune V of Bamako to FCFA 108 per inhabitant for Djenne. The evaluation systematically reviewed the different mechanisms for financing the district health system with an eye to equity. The conclusion was that there are only two ways to assure the viability of first referral hospitals: subsidies from the State and the ability of communities and health teams to create new forms of solidarity. For this second dimension to develop, it will be necessary to avoid top-down and one-size-fits-all approaches. Efforts to progress towards a consolidated budget by district and to put in place new solidarity mechanisms (premutual and mutual funds) will permit better understanding of the complex, overall financing of the district health system. 88 87 Blaise P, Kegels G & Van Lerberghe W (1997) Coûts et financement du système de santé de cercle au Mali. Studies in Health Service Organisation & Policy 5, 1-130. 88 Camara I (1997) Une expérience mutualiste de gestion directe: le Centre de Santé MUTEC. In: Brunet-Jailly E (ed) Innover dans les systèmes de santé. Expériences d’Afrique de l’Ouest, 360-366. Paris: Editions Karthala. Chalamet P & Diakite K (1997) Bâtir sur l’initiative: l’exemple des ressortissants émigrés. In: Brunet-Jailly E (ed) Innover dans les systèmes de santé. Expériences d’Afrique de l’Ouest, 167-178. Paris: Editions Karthala. Studies in HSO&P,20,2003 103
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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
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operational forms to facilitate int
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that were largely committed did not
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Table 9: Achievements and problems
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1993-1995: first achievements Distr
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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 and 104: etter still, to do it in a way that
Page 105: Table 22. Operating account for23 C
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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