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

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114 The combination of initial training for three to four centres of two to three regional districts had advantages. The support process was shortened, and it created a group dynamic and competitiveness among the people being trained as well as the chief doctors. This seemed a good way to bring the newcomers together. The concentrated training carried risks, and specific solutions needed to be envisaged. To make up for the risk of neglecting the launch of the centre, a cushion of one week was explicitly foreseen in the opening of each centre as well as in-service-training for several days in a working ComHC (Table 8). Another risk concerned management of priorities by the regional and district staff. Some of the centre openings did not follow rapidly enough on group training. A long delay between training and launch considerably reduced a centre’s efficacy. Finally, from the start close supervision remained an integral complement to all these measures. The measures were necessary to avoid laxity and the problems of classical training in series. Practical training, self-evaluation with support from those who had acquired experience, and exchange of experiences all were decisive for bringing about change. The new HIS supported decision making at each level. Its implementation proved to be particularly difficult owing to resistance from projects and national programmes, which each had their own system. 93 Despite a prevailing consensus throughout developement of the new HIS (which lasted more than three years), implementation was at a standstill. Maintenance of the old system as a transitional arrangement became an obstacle to developing the new HIS. As a result, the National Health Directorate decided to generalize it to the whole country, even though some components still had to be completed. This measure was intended to support the acceleration process: it was possible to do monitoring thanks to the new HIS. 94 93 Van Lerberghe W, Coulibaly CO, Sidibe O et al. (1995) Etat d’avancement de la réforme du système d’information (SIS) au Mali. Report. 28p. Bamako: Projet Santé Population et Hydraulique Rurale - Ministère de la Santé, de la Solidarité et des Personnes Agées. Van Lerberghe W (1993) Proposition pour une réforme du SIS: mise en place d’un système local d’information sanitaire. Report. 132p Bamako: Projet Santé Population et Hydraulique Rurale - Ministère de la Santé, de la Solidarité et des Personnes Agées. 94 And to the software program DESAM, a geographical and cartographical database that relates information about resources to HIS data on care and morbidity. Studies in HSO&P,20,2003
Faced with increasing pressure, technical staff developed coverage scenarios using the performance of the first ComHC to show that it was advisable to wait for completion of district plans. These illustrations proved to be very useful for supporters and major participants by providing arguments that confirmed the strong basis of the strategies. It was no longer a question of whether it was possible to achieve such coverage or such results. It was clear that it was possible. The question was rather one of setting more reasonable deadlines. In December 1994 an external evaluation preceded the mid-term review of the HPRWP. It determined the significance and quality of progress achieved. 95 In particular, the risks of moving too quickly and certain obstacles (drug issue and availability of staff at the operational level) were identified. Development of community capacities required sustained attention. The process was not ending, but beginning. The pressures diminished, and external partners were anxious to express a position at one with the government in recognition of progress achieved. 96 This show of unanimity was the first of its kind since the declaration of the new health sector policy in December 1990. It involved the principal external partners who supported the health sector. Visible results Things were moving forward. A genuine acceleration was in progress. It was estimated that 900,000 people benefited from health centre services offering the MPS. This constituted more than one-tenth of the Malian population. 95 de Champeaux A, Hours B, Maiga M et al. (1994) Evaluation à mi parcours du PSPHR. 5- 23 December 1994. Report. 144p. Bamako: Projet Santé Population et Hydraulique Rurale. 96 Gouvernement de la République du Mali (1995) Communique de presse conjoint gouvernement-bailleurs de fonds dans le cadre du Projet Santé Population et Hydraulique Rurale. 2p. Studies in HSO&P,20,2003 115
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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
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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 and 116: priority was always given to the se
Page 117: When achievements started to mount
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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