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

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18 rather than planning for district health development. A few regions were farther along in the detailed preparation and finalization of district health development plans, but these regions were not included in the programme (Sikasso), or were only included in the second phase (Ségou). In contrast, Kayes Region, which had no decentralized programming experience, became part of the first phase. At least one functioning ComHC. The criteria for the ComHC test, which were supposed to be satisfied six months after inception, 17 appear to have been difficult for many of the staff to fulfil in such a short time. The region that did manage to put some ComHCs in place (Kayes) did not have a detailed district health development plan, and it is not clear how well these ComHCs worked. Indeed, once these test cases were launched under the HDP, they were no longer supervised. The long and poorly organized transition between the HDP of Kayes Region and HPRWP unfortunately did not take this factor into account. Seven per cent regional and local development tax. A major part of the local tax was allocated to health. This allocation was mainly used by the local development committee to reimburse salaries of matrons and auxiliary nurses. Tax recovery nevertheless varied from one region to another, and following the major political events of March 1991, it collapsed in all the regions. Only with the advent of the Third Republic in 1993 did it significantly improve. Regional support. The regions were assigned a key role in decentralization and in developing a health system based on the principles of the health district. Close to the operational level, the region provided support to the district health teams. Implementation and transformation tools, however, were neither developed nor adapted. This was the case for the Health Information System (HIS) and in particular for the local information system, training methods and modules, standards and procedures, and methods and approaches to involve communities. All these tools still needed to be developed or finalized. In a country where distances are great and communication difficult, the regional level is essential in leading change in the health system. Not all the regional offices had the desired management potential and experience. Under the programme, the support capacities of the regions were reinforced by providing them with 17 Community investment in and management of the centre, MPS, coverage, and balanced operating accounts. Studies in HSO&P,20,2003
technical assistants who were experienced in primary health care management and district health systems. These advisers did not have any direct responsibility for managing financial resources. They had to use their experience to support the regional and district teams in implementing initial tasks. That meant training for all (local, district, and regional levels), and helping to bolster implementation. NEW ROLES FOR PARTICIPANTS AT THE CENTRAL LEVEL The new roles and responsibilities for the different levels were designed to overcome the obstacles of inadequate organization and central functioning. These roles were strongly influenced by the compartmentalized and direct management of programmes. For many participants, notably at the central level, the new policy was dismissed as an additional large project that would gradually assume its place among others already under way. They did not see it as a tool for organizing and decentralizing health development. Indeed, a decree assigned management of the Technical Committee to the director of HPRWP, instead and in place of the National Health and Social Action Department. This move reinforced the tendency of the latter to treat the new national health policy as just another project. The lack of “ownership” of this project generated all the more problems because the health organization model was new throughout Mali; it had not been implemented anywhere. Existing milestones were either partial implementations in a few locales or similar models developed in other countries. 18 It was still an idea awaiting concrete application: making it work could only happen in the field, by establishing ComHCs and the district health development plan. 18 Equipe du Projet Kasongo (1981). Le Projet Kasongo: une expérience d’organisation d’un système de soins de santé primaires. Annales de la Société belge de Médecine Tropicale 61 (Supplement), 1-54. Fassin D, Jeannee E, Salem G et al. (1986) Les enjeux sociaux de la participation communautaire. Les comités de santé a Pikine (Sénégal). Sciences Sociales et Santé 4, 205-221. Stroobant A (1979) Expériences de soins de santé intégrés au Cap Bon, Tunisie. Annales de la Société belge de Médecine Tropicale 59 (Supplement), 47-70. Unger JP (1992) Role des districts sanitaires et méthodologie de leur développement en Afrique. Dissertation. Brussels: Université Libre de Bruxelles, Faculté de Médecine et de Pharmacie. 357p. Studies in HSO&P,20,2003 19
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: 1990-1992: towards a strategy for c
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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