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

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26 months—were necessary to produce a community health association (ComHA) and to launch a ComHC in a health area. This process made it possible to modify the initial theoretical map. It was progressively improved through negotiations and changes of health areas in operational regions. For example, the health map of Koulikouro included some villages in neighbouring districts, and a good number of villages “changed areas” in the course of negotiations (Fig. 6). The map became an indispensable planning instrument, increasing the role of the district team in relation to partners. 23 Figure 6. The health map of Koulikoro, after negotiation with the community in the theoretical region of Chola, October 1995 Partitioning the districts all at once was preferred over doing it gradually. That made it possible to have a view, albeit theoretical, of the global coverage of 23 Samake S, Dakono G & Guidetti F (1997) La carte sanitaire: outil de négociation pour le développement sanitaire? In: Brunet-Jailly E (ed) Innover dans les systèmes de santé. Experiencés d’Afrique de l’Ouest, 73-84. Paris: Editions Karthala. Studies in HSO&P,20,2003
the district, and to assess what human resources and materials were needed. It was also the only way to determine the impact of each health centre initiative on the neighbouring areas. Because each village necessarily belonged to one health area, it clearly defined the burden of responsibility for each existing or proposed health centre. At first, this approach met with some resistance, which centred on the following questions: Why should the district team produce an overall map?Does this not just duplicate administrative thinking? Why talk of areas of responsibility and not of attraction sites or ranges of easy accessibility? Why risk viability by reducing the size of the urban population from 40,000 inhabitants to around 15,000 inhabitants? Isn’t there some way to establish the desired relationship between users and auxiliary nursing staff in urban areas without incurring this risk? Opposition came from different sides: technical assistants of bilateral projects, chief doctors of Bamako ComHC, and NGOs, which had health centres or maternity hospitals in their intervention areas. The debate was complicated because many of the participants were critical of the State delegating responsibilities to a ComHA in each area of responsibility. The private medical network is underdeveloped in Mali 24 : it is limited to Bamako and to certain big towns. In the Malian context, and particularly in the rural setting, the for-profit private sector developed very slowly and initially in cost-effective areas. Thus, it does not pose a credible alternative for health coverage for the near future. Insofar as its purpose was lucrative, it fell outside the contractual framework on which coverage plans were based. Nevertheless, some confusion arose between private-for-profit initiatives and contractual delegation to a ComHA. Incertitudes notwithstanding, Table 4 illustrates the pragmatism and the concern for equity that characterized the approach. While the health sector experience serves as an example for implementing the government’s decentralization policy, it is worth noting that uncertainty will continue to characterize planning of future rural communes. The criteria for administrative division are not necessarily the same as those used by the health sector. 24 The private pharmaceutical network has grown spectacularly, from several outlets to more than a hundred in less than two years. Although recent, the private pharmaceutical sector is organized into professional associations with very active interests. These associations always been involved in the driving process of health sector policy. Studies in HSO&P,20,2003 27
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 and 28: plans started with a discussion of
Page 29: extending coverage. Initially, each
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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