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

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28 Will the rural communes ratify the negotiated division of the health map? Can they allow for one to three health areas without having to redraw the map? What will happen to the relationship between the communes and the ComHA if basic services devolve to the communes? These questions no longer depend only on the health sector. What has been achieved up to this point could still undergo major changes. 25 Information gleaned in forming rural communes often seems to reinforce efforts made by the health sector. In a very few cases we will face a real problem. Concerning the relationship between the communes and the ComHA, one can imagine that in the future, ComHA will assume more the role of an association of commune partner users. Table 4. Advantages and disadvantages of criteria used for the health map Advantages Disadvantages • Allows formulation of plausible hypotheses about district health coverage for the medium and long term. • Replaces the isolated initiative of the health care establishment with a global context of district coverage, promoting rational decision making. • Gives the district team the responsibility for negotiating with those who wish to support district health coverage. • The ComHC has responsibility for the health of the community for all the villages comprising the health area—a different approach from simply responding to demands presented to the health centre. • Local costs are transparent and controlled by the community. • Focuses on a common tool for villages Studies in HSO&P,20,2003 Inclusivity • The need to plan and budget improvements may create combined pressure to proceed much more quickly everywhere, despite insufficient support capacities and other unmet conditions. • Conflicts with participants—e.g., NGOs—who wish to target support to a particular village. Defined area of responsibility • Involves additional operating costs and opportunity costs through itinerant activities for the villages far from the health centre • Invites criticism from (i) indiscriminate advocates of a market economy approach for health services in developing countries and (ii) those who contest responsibility at this level for 25 Ballo M, Duponchel JL & Traore S (1996) Décentralisation et mise en oeuvre de la politique sectorielle de santé et de population. Série d’aide-mémoires. 7p. Bamako.
of the area. • Guarantees a minimum package of services to the community of the area so long as the ComHC is financially sound and bound by agreement. • Strengthens a sense of “ownership” and, for village participants, of having a role in shaping the health area • The actual map and its implementation (ComHC) evolves slowly owing to the fact that reciprocal commitments of partners (community and government) depend on the results of negotiations. The process makes the gains robust, and helps to anchor them. THE MPS Negotiations preventive care activities and favor their total subsidy by the State • Time-consuming • Agreement is often not unanimous • Villages may refuse to stick to the health map, or having signed on to it, may decide to withdraw Process • Negotiations can drag on. • Instability can threaten the plan’s viability if defecting villages find alternative solutions too quickly. • Modifications should cease with implementation to provide opportunity and time to expand the agreement to non-participating villages. The situational analyses of the first districts to develop plans all focused beyond the diversity of their situations towards a unified structure for a curative, preventive, and promotional “package of health services”. Apart from the burdens and priorities attributed to each problem in a given area, the similarities were striking, even when the teams carrying out the exercise were different. The similarity was sufficient to define a minimum package of health care services (MPS): this definition had important consequences for planning and programming in all health areas (nature and importance of equipment, initial provision of drugs, training, support for management, structure of the premises, personnel needs, and so on). Studies in HSO&P,20,2003 29
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 and 30: extending coverage. Initially, each
Page 31: the district, and to assess what hu
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
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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
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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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