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

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110 ineffective and inefficient without revising nurse training school programmes, and without standardizing recruitment of matrons at an acceptable level. Some proposals for revamping health school training programmes were formulated (in particular in the nursing school of Sikasso which actually implemented them). But the years go by, and the preparatory phases endure at the Bamako secondary health school, the main training institution for paramedical managers. The problem of basic training for doctors also arose, but less critically. The new context demanded versatility. Doctors needed surgical and management skills that were generally not taught in medical schools. In certain districts, and after the team had been through the crucial stages (e.g., developing the plan and negotiating the map), transfers were made without taking into account their impact on the team. That brought some districts back to square one. In other circumstances there were unfortunate cases of serious illness and death. In countries where managers are rare in rural areas, these phenomena need to be taken into consideration. Limited logistical capacity and support. The early implementations enjoyed significant logistical support from UNICEF. Government logistical support capacities were not appropriate and constituted a serious obstacle to moving forward quickly. The pace of development, which was slow at the beginning, concealed these problems. Soon the logistical problems became a rate-limiting factor. The support capacities of regional teams were inadequate. They were supposed to develop the whole district health system, which included not just the ComHC but also the referral hospital service. Automatically reverting to external technical assistance to meet this need would run the risk of compromising adaptation. The natural tendency of technicians to reinvent the wheel would have generated more problems than solutions. Decentralization was one of the essential orientations of the new sectoral policy. There was a consensus about its need and justification. But doesn’t wanting to move quickly ultimately risk strengthening the case for centralization? Time available for staff at the operating level was divided among follow-up activities related to implementation of the new policy, vertical programme activities (seminars, central supervisions, national workshops, and so on), and community care services. In this situation of competition, Studies in HSO&P,20,2003
priority was always given to the service imposed or even paid for at the expense of continuity of services. The shortage of human resources, in particular in rural areas, underscored this phenomenon. Guaranteeing quality of care and appropriate management of the new ComHCs, as well as their effectiveness and viability, required minimum support. This support consisted of a series of successive stages: community approach, provision of inputs, training and the launching the new centre (ComHC or R-SDHC), technical supervisions, follow-up, and evaluation. Eighteen months (including the six months of initial functioning) proved sufficient to establish a ComHC and bring it to an acceptable operating level. The performance thus obtained was compatible with attainment of fixed objectives. The workload for the district team was estimated at a minimum of 10 full weeks of work for each ComHC. This constituted a bottleneck could only be reduced to the detriment of the quality of support and potential adaptation by the participants. Few managers had acquired enough experience during the first two years of implementation. Their number increased progressively according to the progress achieved in the chosen districts. They benefited from the support of those who had already had experience. The limits of budgetary decentralization. Budgetary decentralization is not part of and does not strengthen the process (Fig. 21). It is projects such as the HPRWP that underpin the current effort. Previous years demonstrate that the global increase in the health budget has essentially benefited the financial transactions made at the central level and not those of the regions. It appears that at the time, there was more budgetary recentralization than decentralization. Studies in HSO&P,20,2003 111
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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
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evaluation of the approaches was po
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approach through negotiations, with
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Figure 9. Performance in the health
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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 and 110: 1994-1995: Scaling up and improving
Page 111 and 112: implementations and their acceptabi
Page 113: Extension of coverage had to be acc
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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