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

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112 Percentage 18 16 14 12 10 8 6 4 2 0 Figure 21. The portion of regional budgets in the health budget 1990-1996 Studies in HSO&P,20,2003 1990 1991 1992 1993 1994 1995 SOURCE: CPS Ministry of Health The persisting problem of integrating vertical programmes The new policy was not implemented all at once; the old vertical programmes continued to operate, and others were even added to them (e.g., dracunculiasis and distribution of contraceptives at the community level). Officially this was supposed to be an interim arrangement while waiting for decentralization and progressive integration. The desire for seamless change concealed a range of problems; the reality was the status quo, or even a reversal. Confusion persisted concerning the integration and effective decentralization of the services comprising the MPS. None of the vertical programmes had begun an explicit transition. Hesitating to question methods of management and integration, programmes continued to benefit from financing of external partners who were not always approving of the on-going process. Preoccupied with their programmes or specific projects, the latter were concerned about maintaining an influential partner.
When achievements started to mount up, the chief doctors and regional managers began to criticize the excessive demands of vertical programmes. The National Health Directorate then took formal measures to prioritize execution of district health development plans. Still, external partners and managers of programmes at the central level used the pretext of insufficient coverage to justify their parallel interventions. Despite the will of some, problems of coordination and harmonization of interventions at the central level were not easy to resolve. At the beginning of 1994 the National Health Directorate organized consultation days with the participation of all the divisions and regional offices. The differences in levels of information and reasoning were strikingly apparent. These consultations helped to make progress, but without resolving all the problems. The thinking behind the divisions and programmes of the National Health Directorate was strongly influenced by tradition and the involvement of external partners. The people most closely involved in implementing the new policy had no miracle solution to propose. Nevertheless, they were able to correct the major inconsistencies and to resolve conflicts of priority. Beyond closed arbitration at the central level, the field could hardly best the challenge without an alternative solution. Consequently, programmes were urged to channel their support towards launch of the ComHCs. Once the number of operational health areas exceeded 100, a new, strong relationship was established. External partners and managers of national programmes had a more positive attitude with regard to the new health system. Now the trick was to manage the new risk arising from a flood of proposals for integration originating from projects and programmes. Accelerating without derailing The national technical staff and expatriates all expressed doubts about the chances of success for rapid acceleration. Their convergent positions mitigated the demotivating effect of pressure. It was possible to plan a few measures for speeding things up. Establishing the first ComHC was a nucleus that allowed the district team to be formed gradually and to avoid possible apathy (including from within), when transforming a State health centre. Thereafter, it was possible to revitalize SDHCs more rapidly than to set up other ComHCs: the infrastructure and the staff were already in place. Studies in HSO&P,20,2003 113
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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
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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 and 114: Extension of coverage had to be acc
Page 115: priority was always given to the se
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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