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

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