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

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An explicit implementation strategy
In 1991, a first step towards change was taken by redefining the ComHC. 19
Ways of setting it up and its function were clarified, as well as the
relationship of the ComHC with the State. Prepared by an ad hoc group
comprising staff from the Ministry, architects of previous projects, and
resource persons, the document was widely discussed by other institutions
and authorities. It was adopted by consensus and contained major
innovations: (i) the ComHC would be free to define its area of
responsibility; (ii) the relationship with the State was to be a partnership
based on a formal agreement; and (iii) the community association that
managed the ComHC needed to be recognized legally.
The strategy was favourably received by politicians. It allowed
planning for extension of health coverage in an original way, the
administrative division becoming a factor to take into account and not a
non-negotiable constraint.
The initial challenge was to translate the principles and orientations
of the new health sector policy into coherent actions. And that was fraught
with difficulty. Because the tasks of implementation were many and large, it
was necessary to organize and to prioritize them to achieve steady,
systematic progress. The participants had neither referral experience nor
tools adapted to transform the status quo. In the two years following the
events of 1991, the political climate of Mali was marked by successive
changes at the head of the Ministry of Health and of heads of central
departments (four ministers and four national directors of health in less
than two years).
In contrast, the regions were encouraged to take initiatives. At the
same time, they benefited from strengthening of their technical support
capacities, allowing room for experience and innovation in the field. These
advantages would prove useful during the following stages, when conditions
for pressing ahead were more favourable.
Implementation turned out to be more the product of extensive
dialogue than a deliberate move at the central level. Of course, some
participants had broad visions and suggested steps to take; the problem was
19 Direction Nationale de la Santé Publique (1992). Rapport du groupe de réflexion sur le
CSCOM. 8p. Bamako: Direction Nationale de la Santé Publique, Ministère de la Santé, de
la Solidarité et des Personnes Agées.
Studies in HSO&P,20,2003