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

More documents

Recommendations

Info

128 occurred, the concerns, impatience, and institutional interests of different parties would have been cause for attempting change. The interest manifested by many partners provided time to establish the new policy in the field. The multiplicity of centres and decision levels among the external partners 103 constituted a serious constraint in coordinating support for implementation. Financial procedures varied from one partner to the other, which does not always favour operational coordination of cofinancing. The latter became a system of parallel financing, with each partner looking to develop its own areas to achieve a coherent and independent project. Instead of strengthening convergence, complementarity, and flexibility, parallel financing was a setback. It is true that centralization of national budgets on the one hand, and the absence of a consolidated budget by the districts on the other did not favour the desired evolution. When areas of intervention are well defined, the group of external partners can play a useful pivotal role for all and above all for the government and the country, while ensuring the coherence and the complementarity of total support. Effective coordination of external partners whose delegations have real power in the country facilitates negotiations and allows decisions to be made at the site of implementation. Negotiation apart from financial agreements did not always maintain initital cohesion. The coordination and complementarity of support from the government of Mali, the World Bank, and UNICEF was decisive for concretizing the new policy. The flexible design of the Mali-UNICEF Health Programme allowed preparation of different elements, and in particular district development plans and establishment of the first ComHCs. 103 Is it not the insistence of external partners that contributions go through NGOs rather than the administration simply a panacea? No one can deny the significance of NGO contributions, but they should be set in the context of the national policy. It is hard to see how external partner-NGO relationships can make this arrangement work without taking into account the role of public administration in control and orientation. There is certainly a happy medium to be found here that avoids the bureaucratic constraints, and encourages innovation and initiative, while still being part of a national development process. The sectoral policy offered the Ministry of Health a suitable framework for such coordination. And the successes in implementation gave it the credibility it needed to negotiate external support provided by the NGOs. Studies in HSO&P,20,2003
Joint central supervision 104 played a very important role in the process of change and its diffusion. These field visits were undertaken by the National Health Directorate, with the HPRWP and UNICEF. They also often involved one of the external partners, in particular the WHO. The supervision missions allowed the central level to have a better appreciation of the field. Through their participatory approach they also involved all the participants (e.g., ComHA, ComHC health team, district health team, and regional team). Corrections were made in the field, and a consolidated report was systematically shared with all the regions and central offices. In this way, problems in implementation could be handled and sometimes resolved. The approach was shared with regional teams who provided continuous support in the field. Leadership was represented by a critical mass of staff sharing the same principles and a good sense of collaboration, negotiation, and partnership, in Mali’s overall favourable political context of democratization. The necessary alliances among external partners were created to overcome obstacles. It takes time to put a reform of such magnitude in place. Negotiations, adaptation, and learning all proceed slowly. Moreover, the critical mass of health professionals is limited, and transforming the health system is a lengthy process. Each situation has its own best pace for advancing without losing ground. The involvement of representatives from civil society can help in reconciling the health services and the community, allying them side by side to face the challenges of development. 104 Projet Santé Population et Hydraulique Rurale (1992-1996) Série de rapports de revues conjointes, gouvernement-bailleurs de fonds du projet. Bamako: Projet Santé Population et Hydraulique Rurale. Studies in HSO&P,20,2003 129
Page 2 and 3:
Studies in Health Services Organisa
Page 5 and 6:
Acknowledgements The authors partic
Page 7 and 8:
Limits of past experiences A new he
Page 9 and 10:
purchase drugs from the dispensarie
Page 11 and 12:
workshops and specialized studies b
Page 13 and 14:
Community participation in managing
Page 15 and 16:
decentralization, and integration o
Page 17 and 18:
esearchers were often involved in d
Page 19 and 20:
Achievements and problems Declarati
Page 21 and 22:
1990-1992: towards a strategy for c
Page 23 and 24:
technical assistants who were exper
Page 25 and 26:
making all the right decisions at t
Page 27 and 28:
plans started with a discussion of
Page 29 and 30:
extending coverage. Initially, each
Page 31 and 32:
the district, and to assess what hu
Page 33 and 34:
of the area. • Guarantees a minim
Page 35 and 36:
Health (to such an extent that some
Page 37 and 38:
THE ISSUE OF ESSENTIAL DRUGS From i
Page 39 and 40:
The new strategies were developed w
Page 41 and 42:
That may appear simple and obvious,
Page 43 and 44:
managerial instrument tools for fol
Page 45 and 46:
operational forms to facilitate int
Page 47 and 48:
that were largely committed did not
Page 49 and 50:
Table 9: Achievements and problems
Page 51 and 52:
1993-1995: first achievements Distr
Page 53 and 54:
Methods workshop 2 weeks Finalizing
Page 55 and 56:
evaluation of the approaches was po
Page 57 and 58:
approach through negotiations, with
Page 59 and 60:
Figure 9. Performance in the health
Page 61 and 62:
In Dougouolo, a survey 45 revealed
Page 63 and 64:
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 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 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: commitment score 5 4 3 2 1 0 -1 -2
Page 135 and 136: Table of contents Acknowledgements
show all

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?