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

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32 Table 6. The alternatives: global convention or specific contracts for each vertical programme Global convention Specific contracts Care • Access to care coverage • Balanced for the MPS • Lasting progress • Specific performance may be modest Studies in HSO&P,20,2003 • Improvement for the specific activity of the contract • Specific results more rapid, but not lasting • MPS • Complete at the beginning • Incomplete if activities not covered by a contract • Quality of care • Favours global responsibility • To make the community accountable Development • The community and its needs constitute the reference frame • Partner • Continuity • The stakes are clear: survival of the ComHC • Motivation of personnel • Through responsibility for the ComHC and the whole community • Sense of ownership of the ComHC as a working tool • Premiums possible for performance and global quality of services • Favours programme performance but lacks integration • Reference to programmes and their technicians becomes predominate • Programme target • Threatened because linked to the successful execution of contracts • Double financing always possible owing to lack of transparency and isolated management reinforced by the perceived advantages a contract brings • Possibility of undesired effects with anomalous results if remuneration is based on performance without local control
THE ISSUE OF ESSENTIAL DRUGS From its creation in 1962, and until 1983, the PPM was responsible for importing and distributing drugs to the public. The hospital sector and public services network were supplied by the central pharmacy of the National Health Directorate. The private sector was confined to a single pharmaceutical dispensary in Bamako. In 1984, following pharmaceutical reform, the PPM appointed itself to import and distribute drugs to hospitals and public services, effectively establishing a monopoly. In 1985 and 1986, laws liberalizing the health professions and pharmaceuticals raised questions about this monopoly. But in 1987, the PPM moved in the opposite direction, signing a comanagement agreement with China that formalized the monopoly. The question came up again in agreements governing the structural adjustment of public enterprises. These agreements, concluded with the Bretton Woods Institutions, called for the PPM to be restructured and to cease from distributing drugs in favour of the private sector before December 1989. Negotiations with the World Bank to implement the new health sector policy put an end to the PPM monopoly, though it was still accorded a major role in importing and distributing essential drugs. The decision undercut a part of the Bamako Initiative conceptual framework defined in August 1989: the PPM had been expected to import and distribute essential drugs to the benefit of public and community structures. 27 In other words, the PPM’s contract with the government required it to import and distribute essential generic drugs. 28 Signing the contract was a condition of the World Bank loan. But now the PPM had to reduce the number of its personnel from 650 to 200, give up nearly all of its dispensaries to the private sector, stop importing brand-name specialty drugs in place of essential generic drugs, and compete with new private importers of drugs (rapidly put in place with credit assistance from French drug exporters). The PPM retained its commercial nature but lost all its 27 Brunet-Jailly J (1990) La Pharmacie Populaire du Mali dans le contexte de l’Initiative de Bamako. 137p. Bamako: Institut National de Recherche en Santé Publique - UNICEF. 28 Ministère de la Santé, de la Solidarité et des Personnes Agées (1992) Contrat plan Etat - Pharmacie Populaire du Mali. Bamko: Ministère de la Santé, de la Solidarité et des Personnes Agées. Studies in HSO&P,20,2003 33
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 and 34: of the area. • Guarantees a minim
Page 35: Health (to such an extent that some
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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