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

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10 Level Table 2. New functions by level Structures Function National • Ministry of Health, • Orientation and central office strategic planning, • National hospital definition of standards and procedures, evaluation • On-going training • Specialized care Regional • Regional office • Technical support to the • Regional hospital districts • Second referral level care District • DHC (first referral • Planning/administration level hospital) management • Referral care • Supervision of the first level Village group, urban areas • ComHC or SDHC • Minimum package of health care services with community management Principal participants PARTICIPANTS WITHIN MALI For a variety of reasons (linked to commitment and international visibility), politicians maintained a favourable attitude during this process. In particular, they signified their support for a policy of decentralization and of responsibility and involvement of the community in the health sector. The Bamako Initiative and the government’s declaration were both formally adopted by the government in the Council of Ministers. Health professionals at all levels of the Ministry of Health were involved and contributed at each stage, particularly through numerous working committees. Although enthusiastic, they sometimes had reservations about specific points related to their position or responsibilities. Apart from the issue of drugs—which was dominated by contradictions and emotions—the overall response was very positive. However, a certain scepticism was evident with regard to community participation, Studies in HSO&P,20,2003
decentralization, and integration of a few of the vertical programmes. Some of these had become veritable institutions, benefiting from significant political support. A failure to reorganize central structures to fit new tasks occasionally led to perpetuation of the existing system, to the detriment of change. Certain communities (e.g., municipalities and local development committees) had amply demonstrated their commitment by constructing health centres and paying salaries for support staff. They often allocated more than 7% of their development tax to the health sector. The community already met 75% of health expenditures. 12 The ComHC trials, and the cost-recovery system under way in certain localities, demonstrated people’s willingness to pay for quality services. However, apart from areas that supported organization projects, such as village associations or the Ton, management capacities were weak. EXTERNAL PARTNERS WHO supported the efforts of national health professionals during all the stages of the 1980s, in particular those aiming to decentralize and integrate programme management. WHO also supported vertical programmes, including those undertaken on a large scale at the end of the 1980s, for example, EPI and MCH. At the decisive stages its role was less visible, though that did not imply distancing. UNICEF developed one of the largest support programmes for the health sector. It played a dynamic role at all stages of development, and amended the 1988-1992 cooperation programme to provide financing under the Bamako Initiative. UNICEF integrated and later encouraged the process of cofinancing the national programme with other partners and participated in a joint evaluation mission with the World Bank to launch a new national programme (the HPRWP) in May 1990. Technical assistance was offered to the regional offices. While support of the organization towards government efforts for defining a national policy was adequate, it should be noted that the intensity and vigour applied to reinforcing the EPI, a vertical programme in itself, was not in harmony with the problems and local priorities of the time. Between 1984 and 1988, the World Bank-supported HDP, in Kayes Region, focused on three districts. The HDP approach had been that of a 12 Coulibaly S & Keita M (1993) Les comptes nationaux de la santé au Mali. 1988-1991. Initiative de Bamako. Technical Report No. 18. 71p. New York: UNICEF. Studies in HSO&P,20,2003 11
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: Community participation in managing
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
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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
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ambulance evacuation by the health
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The ComHA-BA—the community health
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maintaining the centre’s capacity
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Table 15. Effects of contractual mo
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Motivation of health staff received
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Financing of the sector and viabili
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financing of the ComHCs was conside
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to placing the complex and costly r
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Profit on drugs. Another aspect tes
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These simulations deliberately favo
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Table 20. Distribution of investmen
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Results for the first ComHCs projec
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The answers to these questions emer
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Specific contracts had no justifica
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etter still, to do it in a way that
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Table 22. Operating account for23 C
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1995. Even though begun, this evolu
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1994-1995: Scaling up and improving
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implementations and their acceptabi
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Extension of coverage had to be acc
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priority was always given to the se
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When achievements started to mount
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Faced with increasing pressure, tec
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Figure 24. Performance achieved in
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SDHC; on the right, the area that b
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situation opened prospects for inte
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Managing change Without the project
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Figure 27. The position of national
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commitment score 5 4 3 2 1 0 -1 -2
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Joint central supervision 104 playe
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Table of contents Acknowledgements
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