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

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122 That is the principle underpinning the ComHC strategy. It is too premature to evaluate it, and it will not happen spontaneously. It will take the support and oversight of people who have a clear perception of the potential advantages to this new situation to overcome the inherent obstacles and difficulties. 101 Progress in this domain will depend on the overall evolution of Malian society, and effective and realistic decentralization—not hollow idealism and dull theories. There is no doubt that the greater the community’s skills in negotiating with the health services and the administration, the more the community will assume responsibility. To promote a healthy partner relationship, the ComHA must be autonomous. Regrouping into a federation reinforced the ComHA’s negotiating capacity. The Federation of Community Health Associations held its inaugural conference in July 1994. It constituted a significant achievement, but was not immune to artificial politicization. Defining the relationship between the ComHAs and future rural communes will be very important in developing the sector. Contractual delegation of ComHC management by the State and the community to the associations represented by the ComHAs are what makes the Malian experience original. This approach is based more on effective decentralization and autonomy of communities than privatization in the liberal sense of the term. These ComHCs have a public service role. The ComHAs should be accountable to the community from which they emanate and to the administration in the context of regular reviews of agreements. 101 Le Jean Y (1997) L’expérience associative: vulnerable et irremplacable. In: Brunet-Jailly E (ed) Innover dans les systèmes de santé. Expériences d’Afrique de l’Ouest, 117-131. Paris: Editions Karthala. Studies in HSO&P,20,2003
Managing change Without the projects and experiences of the 1980s and their contribution to training field staff, it would not have been possible to envisage implementation or even to formulate a new health sectoral policy in Mali. The latter was all the more credible because it was supported by achievements and lessons from the past, and because the need for change was obvious to all participants. The design of the health system and the role that the State was expected to play made the present different from the past. Completion of several parallel and often contradictory actions to achieve coordination among all parties was equally important. For a policy to succeed, it has to have resources. In Mali, the commitment of principal partners of the sector clearly constituted a success factor in its effective implementation. This commitment was different from the disparate and non-coordinated support of the 1980s. The involvement of diverse national participants was also determinant. The health system in Mali was too weak to support change imposed by the administration and half-hearted collaboration. The consecutive changes in the new policy disrupted established traditions and interests. The motivation of some participants and the inertia or the resistance of others all had to be reckoned with. Experience demonstrated that the positions were not immutable. They changed from one stage to the other. Each stage—and there were four of them—had its stakes and alliances. The first stage was that of policy definition, from 1989 to the beginning of 1991. The second stage was the period of trials and of developing strategy. This was a phase of researching methods, tools, and approaches to implementing and realizing the first ComHC and district health development plans. It began in 1991 and ended in 1993. The third stage was the first results: actual implementation of the first ComHC and approval of financing for the first district health development plans. This stage began in the middle of 1993 and continued up to the end of 1994. It was followed, at the end of 1994, by scaling up implementation and was marked by external evaluation and mid-term review by the HPRWP. At the beginning there was little opposition to the principles of the sectoral policy, apart from the active resistance of certain professional Studies in HSO&P,20,2003 123
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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
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contributed to the debate at the na
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Organizing and developing referral
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on these experiments, but in both s
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% 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 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: situation opened prospects for inte
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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