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

Community participation in managing and mobilizing resources for health
was also considered basic to implementing the new health policy. Planning
for coverage by the ComHCs would no longer be done in a top-down
fashion, but would take into account the distribution, commitment, and
motivation of the community. Once these principles were established,
implementation could begin, in particular, extending coverage and
strengthening technical services at the first referral level hospitals. The
decision was made to start where the conditions for success seemed best. A
series of eligibility criteria were defined for candidate districts to satisfy in
order to receive support (Table 1). The grouping of the criteria was
innovative. Each taken separately derived from the experiences or lessons
learned from various projects.
Table 1. Selection criteria for eligible districts
1. The district health team should include at least two doctors.
2. The district should develop a five-year health plan.
3. The district should have implemented a functioning ComHC, proof of its
technical wherewithal, and ability to promote the organization and
responsibility of communities for their health.
4. The communities must commit themselves to contributing financially and/or
materially to at least 25% of the renovation or construction cost of the
ComHC, the rest coming from the State.
5. The Local Development Committee should commit itself to devote at least
7% of the regional and local development tax to the health sector.
6. The Regional Health and Social Action Office helps the districts to meet
these conditions.
The conditions had to be met as a package to avoid certain mistakes
of the past. This innovation created anxiety among a number of staff who
perceived it as a barrier to obtaining financing.
Involvement of all levels of health organization was essential for such a
programme to work. And the tasks of the different levels needed to be reexamined
from the vantage of decentralization. From now on, the district
would take care of planning, management, and execution, and the regional
level would provide technical support and regional coordination. For their
part, central services were limited to defining policy, strategic planning, and
evaluation. But the onus was equally on them to mobilize resources and to
ensure coordination of support from external partners.
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