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

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14 Figure 3. Chronology of commitments (C), financial agreements (A), and release of funds (grey) by the partners of the HPRWP Mali Government C A World Bank US$ 29,760,000 UNICEF US$ 15,398,000 USAID US$ 15,000,000 KFW US$ 8,970,000 EDF US$ 13,081,600 Fonds d’Aide et de Coopération US$ 1,700,300 In fact, rather than joint cofinancing, what actually transpired was parallel financing, each partner following its own specific procedures. 15 Fig. 3 clearly illustrates the process to execution of commitments of external partners (a total of US$ 84 million). The occasional long delay between commitment, agreement, and release of funds was a major difficulty that threatened progress. 15 Some financing varied considerably, as was the case for the USAID contribution, which triple its planned contribution. The additional support was oriented towards family planning. Studies in HSO&P,20,2003 1990 1991 1992 1993 1994 C A C A C A C A C A
Achievements and problems Declaration of the new national health policy constituted a major event. For the first time, the government announced measures informed by past experience and strengthened by debate, with careful attention to the Malian and African context. 16 The new policy defined a framework with objectives and strategies that go well beyond professions of faith. This framework became an instrument for mobilizing and coordinating interventions in pursuit of a national ambition. The coherence and clear strategic choices evident in the declaration increased its credibility for donors. The commitment of a number of principal partners to cofinance the programme made implementation of the reforms a plausible goal. The decennial plan at the beginning of the 1980s did not benefit from such a commitment, and in fact, little of it was ever realized. Genuine enthusiasm was discernible among most of the participants; it was evident that their motivation was equal to the challenges. The convergence of views among committed health staff eased the way to initiatives and concrete actions. Questions regarding implementation still had to be settled (Table 3). The important issue of supply of essential drugs was controversial, and in particular, the steps needed for the PPM—a quasi-commercial public enterprise—to assume this task. Everything that concerned availability of essential generic drugs moved slowly. In contrast, transfer of the PPM’s distribution network to the private sector happened remarkably quickly. Measures needed to create the legal and regulatory environment for new orientations (e.g., decentralization and community participation) were not yet in place. The means for managing the transition from a programme- 16 World Bank (1991) Rapport d’évaluation du Projet Santé, Population et Hydraulique Rurale, République du Mali. Report. 204p. Washington: World Bank. Koita A, Brunet-Jailly J, Coulibaly S et al. (1989) Recurrent costs in the health sector. Problems and policy options in three countries (Costa Rica, Jamaica, Mali), 45-92. Geneva: World Health Organization. (WHO/SHS/NHP/89.10). Pangu KA (1990) La santé pour tous d’ici l’an 2000, c’est possible: Expérience de planification et d’implantation des centres de santé dans la zone de Kasongo au Zaire. Dissertation. Brussels: Université Libre de Bruxelles. 325p. Projet de Développement Sanitaire du Mali (1987) Réflexion sur le système de santé de district. Working Paper. Brussels: Projet de Développement Sanitaire du Mali, Medicus Mundi Belgium. UNICEF-Mali (1989-1996) Série de rapports de revues annuelles et à mi-parcours et notes techniques. Bamako: UNICEF. Studies in HSO&P,20,2003 15
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: esearchers were often involved in d
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
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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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