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

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24 Complementary field support was necessary to translate the proposed innovations into reality. THE HEALTH MAP: A NEGOTIATING TOOL A district in Mali has on average between 150,000 and 200,000 inhabitants, spread over 200-300 villages. It is composed of 4-6 sub-districts with each sub-district including 3-5 development zones. Many development zones had maternities or dispensaries managed by matrons or auxiliary nurses, locally financed by the population or the local development committee. Each subdistrict had a health centre (the SDHC) belonging to the state care system and run by a nurse (Fig. 4). Each district had a DHC, generally equipped with a surgical block and with at least one vehicle solely for the field. The DHC was run by a doctor, often assisted by an associate. Other technicians completed the team: midwife, nursing personnel, sanitary engineer for environmental health activities, and a community development engineer for social activities. Figure 4. Administrative map of the district of Koulikoro: the sub-districts and their SDHCs This existing administrative division (sub-district) often did not meet the technical and financial criteria for ensuring the viability and the quality of services at the SDHC level. For these reasons, the administrative division was not considered to be the absolute standard in developing maps for Studies in HSO&P,20,2003
extending coverage. Initially, each district team disregarded administrative limits and proceeded to partition the entire district into health areas on the basis of geography, population, sociology, and economics. Each area included a number of villages likely to participate and become organized enough to create and run a health centre. The outcome of this initial phase was called “the theoretical coverage map for the district” (Fig. 5). Figure 5. The theoretical coverage map for the district of Koulikoro, 20 June 1993; drawn from data gathered at the different levels (local administration, SDHC, DHC, Ministry of Health, and so on) The initial version of the health map was already very different from the administrative map. It was submitted to the district local managers (e.g., administrative, political, and chiefs of villages), and became a planning and negotiating tool for all the district partners, and in particular for the community, which contributed to the final draft. Numerous interations within the villages and intervillage consultations—sometimes lasting several Studies in HSO&P,20,2003 25
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 and 24: technical assistants who were exper
Page 25 and 26: making all the right decisions at t
Page 27: plans started with a discussion of
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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