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

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30 Studies in HSO&P,20,2003 Table 5. Components of the MPS Curative activities: Control of current infections, including acute respiratory infections, diarrhoea, malaria, current sexually transmitted diseases (STDs), referral of serious cases, and prescriptions for essential generic drugs Follow-up and early detection of some chronic illnesses: Leprosy, tuberculosis Preventive activities: Vaccination of children and pregnant women; nutritional follow-up of children; prenatal and postnatal follow-up for pregnant women; assisted childbirth, and referral of at-risk deliveries and evacuation of complicated deliveries; family planning Laboratory samples: Urine tests, sampling and fixing of sputum (tuberculosis) on slides, and other simple tests Promotional activities: Environmental hygiene and sanitation, promotion of positive nutritional behaviour for mother and child, health education activities, supportive activities for community development Itinerant activities in health area villages: Vaccination, nutritional follow-up, promotion and strengthening of relationships with the local network Management activities: Management of the essential drugs depot, monitoring and control of elements of the local information system (managment control data and use of the service by the village), epidemiological surveillance, schedule management, health centre account data management, minutes of ComHA meetings, production and transfer of the quarterly report to the DHC Defining the components of the MPS was a major objective for the National Health Directorate, making it possible to seriously envisage integrating and decentralizing national programme activities. While the principle itself posed no problem, it took innumerable meetings and (sometimes) heated exchanges before the components were formally made part of the MPS. The debate concerned the following questions: Is it necessary to make a list? Why not include the components among the activities that could follow from the responsibilities and fields of consideration of managers at the central level? Is such a clearly defined MPS limiting, restricting, or indicative? Why not make two types of MPSs, one for the ComHCs managed by doctors, and one for the ComHCs managed by nurses? Why not distinguish the services that the ComHCs will perform anyway (curative care) from those linked to State contracts that provide reimbursement based on performance (vaccination or other preventive and promotional activities)? The debate generated by these questions revealed contradictory concerns. The central managers wished to see the “magnificent tool” that was to be the ComHC carry out all the responsibilities of the Ministry of
Health (to such an extent that some versions strongly resembled the organizational chart of the Ministry of Health in miniature). Another point of discussion emphasized that curative activities are unavoidable but profitable. It would be preferable for the government pay for profitable preventive activities and for those considered not much in demand by the community. While the first proposition risked sinking the “ComHC boat” with inappropriate overload, the second threatened the integration and globality of services, and linked essential activities to specific financing that often depended on outside aid. The position that formed the basis of agreement—generally supported though not unanimous—presented the MPS as a global offer of integrated curative, preventive, and promotional care, taking into account all health problems for which the centre is able to propose solutions. There was no question of subordinating basic activities (considered opportunity cost in for-profit logic) to specific financing in order not to harm the integration and the totality of care. Table 6 compares the global approach with a specific contract approach. It is not just that specific contracts had drawbacks. The choice made in Mali supported an integrated MPS service and a universally reinforced community health network. The mechanisms required to manage a large number of specific contracts between the ComHC and the funding programmes would have been both complex and difficult to control. 26 26 McPake B & Ngalande-Banda E (1994) Contracting out of health services in developing countries. Health Policy and Planning 9, 25-30. Studies in HSO&P,20,2003 31
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 and 32: the district, and to assess what hu
Page 33: of the area. • Guarantees a minim
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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