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

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106 Table 23. Time to launch of the ComHCs and R-SDHCs in Koulikoro Region No. of months 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Tougouni* n c i a Baguinéda* n c i a Boron* n c i a Mourdiah* n c i a Ballé* n c i a Monzombala n c ia Nossombougou* n c i a Kalabancoro n ia Koula* n c ia a Chola n c i a Sirakorola* n c i a Massantola* n c i a Didiéni* n c i a Nangola n c i a Sabougou n c i a Kolébougou n c i a Nyamina* n c ia Moribabougou n c i a Keniégué n c i a Madina Sako* n i c a Naréna* n c i a Goumbou n c i a Dilly* n c ia Kerouané n c i a Cola Bamanam n c ia Massigui* n c i a *SDHC Legend: n = beginning of negotiations; i = training ComHC workers; c = setting up the ComHA; a = training the ComHA. Notes: Tougouni (SDHC), 1995; Baguinéda, 1996; Boron, 1995; Mourdiah, 1996; Ballé, 1996; Monzombala, 1994; Nossombougou, 1995; Kalabancoro, 1994, the ComHA predated the community approach; Koula, 1995; Chola, 1995; Sirakorola, 1996; Masantola, 1995; Didiéni, 1996, ComHA refused to keep the SDHC’s nurse; Nangola, 1995, problems recruiting nurses; Sabougou, 1995, problems with negotiations; Kolébougou, 1994, problems recruiting staff; Nyamina, 1995, rainy season and delay of the district health team; Moribabougou, 1995, negotiated maternity conversion into ComHC; Keniégué, 1995, delay in mobilizing resources by SNV (an NGO from Netherlands); Madina Sako, 1995, delay of the ESSC; Naréna, 1995, negotiation difficult and nurse problems; Goumbou, 1995, support difficult because of distances; Dilly, 1995, support difficult because of distances; Kerouané, 1995, problem recruiting nurses; Cola Bamanam, 1995, difficult negotiations; Massigui, 1996, delay in mobilizing resources by SNV. Within Mali a push came from the political level, which wanted the community to benefit rapidly from the new policy. The government was committed to attain its objectives in a national and international context. It wished to demonstrate the progress achieved in this direction and to advance towards implementation of its objectives. The results of the first Studies in HSO&P,20,2003
implementations and their acceptability by the community led the health authority to support the operationalization strategies while applying pressure to move faster. The ComHA of Bamako and the economic interest group Health for All included many upper-level staff, some of whom were members of political parties. Thus it is not surprising that the problems with implementation and the debate over the strategies resonated at high political levels and contributed to pressure. Another source of internal political pressure was the determination to effectively mobilize resources allocated by donors, notably in a macroeconomic framework. Pressure also came from the community. Following training, discussions about the health maps, and especially through word of mouth as the first ComHCs emerged, people increasingly appealed to the chief doctors and to the regional offices for rapid opening of ComHCs in their areas. Through their citizens living in Bamako, they made direct requests to external partners, for example, small French NGOs or through twinning arrangements. External pressures. The World Bank and UNICEF expressed the most anxiety and impatience over delays in implementation. Other partners showed their frustration to a lesser degree, or not at all. 90 While it is true that USAID developed mechanisms to help in eradicating dracunculiasis and increasing contraceptive use, the agency hoped the objectives would not be a detriment to establishing ComHCs. That was much easier said than done. At the launching seminars of the HPRWP in November 1992 and implementation in February 1993, there was a strong temptation to accelerate development of district plans and to multiply them rapidly. There was certainly pressure from the World Bank in this direction. The preparatory stage of putting in place a foundation for the new health system did not disburse large amounts of money, and its achievements were not very visible. The message was clear: in the absence of significant results in the following months, the HPRWP was in jeopardy owing to inadequate disbursement, in accordance with Bank procedures. Still, this message was moderated by the clear show of sympathy by successive Bank missions to 90 At this stage the other external partners had still not begun disbursements towards implementation (EDF, KFW) or remained on the fringe, indeed outside of cofinancing (FAC, UNFPA). Studies in HSO&P,20,2003 107
Page 2 and 3:
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
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evaluation of the approaches was po
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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 and 106: Table 22. Operating account for23 C
Page 107 and 108: 1995. Even though begun, this evolu
Page 109: 1994-1995: Scaling up and improving
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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