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

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12 two-level health system. 13 This project consisted of national components covering the supply of essential drugs, training of staff, and particularly the review of basic training courses. The first ComHC trials were begun under this project. Many of the staff from the Ministry were very critical of the Kayes Region HDP. Training for staff was positively perceived, but other national components never materialized, and the civil engineering component was too ambitious and seriously delayed. The fact that the project was directly managed by a central unit in place of the usual mechanisms (national and regional directorate) contributed to the negative perception. Renewal of the project and its planned expansion offered an opportunity for discussion and careful thought given to decentralization, community participation, financing, and cost sharing for health services. The World Bank expressed interest in supporting the government under a cofinancing arrangement for implementing a national health policy whose core elements feature in the Bamako Initiative. USAID intervened in Primary Health Care projects, based on the Village Health Workers, and most often in support of non-governmental organizations (NGOs). It backed an MCH reorganization programme for Bamako District and Koulikoro Region, and certain specific programmes (Control of Diarrhoeal Diseases, Family Planning). USAID was in favour of setting up a large national programme cofinanced by principal donors, which took into account the health concerns of the community at the time. The EDF provided support for two districts in the first region (Nioro and Diema). It appeared genuinely interested in cofinancing a national programme where each partner, while making its own contribution, could benefit from the experience of others for the global success of the programme. Support for referral services was among the EDF’s priorities. The Fonds d’Aide et de Coopération Française primarily intervened in the area of training for health professionals, hospitals, and research. It provided technical assistance to several departments in the Ministry of Health and also provided support in the domain of primary health care in Koulikoro Region and through NGOs. The Fonds played a significant role in financial aid and in the context of decentralized cooperation between Malian and French towns and provinces. Technical assistants and French 13 Kegels G & Togola F (1987) Modèle de circonscription sanitaire de cercle. Working Paper. 42p. Bruxelles: Projet de Développement Sanitaire du Mali, Medicus Mundi Belgium. Studies in HSO&P,20,2003
esearchers were often involved in drafting new policy. Strictly speaking, however, the organization’s commitment under the HPRWP was limited to combating iodine deficiency. The Deutsche Gesellschaft für Technische Zusammenarbeit joined the process and expressed its interest to participate in cofinancing the programme as a continuation of its cooperative project in Mopti Region. 14 Bilateral assistance from the Swiss and Dutch, in particular, was occasionally provided through participation of their technical assistants at workshops or in committees. They were not exactly associated with the coordination that led to commitment of principal partners under the HPRWP. Still, their cooperation lent significant support to a number of districts. NGOs were not involved in the process at this stage, but their indirect contribution through innovations and lessons learned was significant (e.g., Medicus Mundi Belgique through the HDP, Médecins du Monde France through a cost-recovery project in Mopti Region, Belgian Médecins Sans Frontières through the Health Shop project of the regions of the north, and Santé Sud in Bamako District). Several Malian health professionals enriched their knowledge, developed expertise, and acquired experience through their involvement in these projects. The declaration of the health sector policy was signed on 15 December 1990. The loan agreement between the government and the World Bank was signed five months later, on 3 May 1991. Activation of the loan was conditional on progress being made on the issue of drugs, on the creation of a favourable legal environment for implementing the project, and on the government signing grant agreements with the EDF, the KFW, and USAID. The loan was scheduled to start 26 March 1992. By this date, only the grant agreement with USAID had been signed. In the climate of political transition that characterized Mali following the events of March 1991, some partners were slow to fulfil their commitments. 14 Berche T & Mariko M (1991) Le financement des couts recurrents de la santé dans le cercle de Bandiagara; analyse économique et santé publique. Report. 112p. Bamako: Institut National de Recherche en Santé Publique. Studies in HSO&P,20,2003 13
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: decentralization, and integration o
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 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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