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

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organizations, especially on the question of drugs (Figs 27-30). The referral
framework was politically acceptable, and the details remained vague to
avoid creating concern. That changed as soon as people began to
experiment and formulate a strategy for change. Some lost their enthusiasm
owing to fear of the unknown, others out of fear of losing power.
The preparatory stages for implementation were much longer and
more complex than initially anticipated. The fact that there was an explicit
reference model facilitated design of the strategy for change. Experience and
innovation were decisive in pursuing dialogue at the strategic level. This
implied proximity to the field, expertise, experiences, and exchanges, in
other words, an excellent vocational school and capacity building approach.
Initial planning, detailed as it was, did not take into account the realities of
a complex and dynamic situation. Its rigid application would have led to a
deadlock. In fact, nothing was fixed in advance, and the major regulatory
measures often followed rather than preceded the first steps.
Even at the heart of the Ministry reservations were perceptible as
strategies were being developed (Fig. 28). The low enthusiasm of regional
staff who were not involved in the first stages shows how it is important to
ensure good circulation of information and to have constructive discussions.
A major difficulty encountered in implementation consisted in positively
managing the coexistence between the new organization of the health
system and the traditional support of vertical programmes. New
developments (e.g., MPS, community management, decentralization, and
integration) needed to gradually expand to assure national coverage.
Therefore, areas still not covered continued to benefit from traditional
support of vertical programmes.
Implementation was not supposed to be a juxtaposition of existing
programmes. Negotiations to decentralize management and integrate
programme activities into the new system proved to be a true test of
strength where the technical and effeciency elements rarely existed at the
first level. The stakes and influences of this test were not only a product of
the Malian context. Decentralization and integration advanced against the
current, and the challenge that arose was to resolve new problems caused by
new programmes offered in the classical format of previous ones. 102
102 El Abassi A (1998) Le processus d’intégration de programmes au sein d’un Paquet
Minimum d’Activités pour les Centres de Santé: l’expérience du Mali. In: Van Lerberghe W
& de Bethune X (ed) Intégrations et Recherche. Studies in Health Services Organisation &
Studies in HSO&P,20,2003