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

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20 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
making all the right decisions at the right time. 20 The gap that existed between goals and actual experience prevented central management from rapidly formulating operational strategies. Despite the many changes at the head of the Ministry and the fact that the health sector declaration was made under a previous government, the policy was ratified by each new Minister. But owing to the laggardly pace and emotional tenor of the debate over essential drugs, reconfirmation of the new policy was hesitant at first. Only on 8 June 1992, with the inauguration of the government of the Third Republic, did instabilities subside. The Minister named at this time was still in his post in 1997. ORGANIZING REGIONAL SUPPORT Implementing the new health policy in the regions was predicated on the districts fulfilling eligibility criteria so they could obtain support for extending coverage and backup of the referral level. That required the districts to develop their plans, create a ComHC test, and negotiate mutual commitments with partners. It also required the Ministry of Health to complete the social-health team right up to actual minimum requirements (Table 1). To avoid dissipating central support and to rapidly learn from useful lessons for the benefit of other regions, the decision was made to work in phases. In principle, three regions were involved in a first phase (Kayes, Mopti, and Bamako); two others (Ségou and Koulikoro) were to follow two years later. However, all the regions needed to provide support to the districts to meet eligibility criteria. Financing these preliminary stages posed a problem: even Kayes, the region of the previous World Bank project, was not able to mobilize the necessary resources at this stage. And as noted earlier, HPRWP only took into account financing for implementation. The problem was resolved with the assistance of flexible financing from UNICEF. Among the three regions of the first phase, two (Kayes and Mopti) presented serious problems of isolation and human resources. In actual practice, the region of Koulikoro—where technical assistance was available only from March 1993—fulfilled the eligibility criteria a little later than the 20 Mercenier P (1992). Rapport de mission de consultation pour définir les priorités et un plan de recherche sur le système de santé. May 1992. Report. 17p. Antwerp: Institut de Médecine Tropicale. Studies in HSO&P,20,2003 21
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 and 22: 1990-1992: towards a strategy for c
Page 23: technical assistants who were exper
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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