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

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36 Table 7. Conditions required for unitary programming by health area 1. The health map is developed. 2. The MPS is defined and adopted in the context of the district. 3. The following inputs are feasible: • Process leading to the creation of the ComHA • Rehabilitation or construction of infrastructure • Standard equipment for the health centre and estimated depreciation • Initial provision of drugs and vaccines and estimate of annual consumption • Training of personnel and of the management committee • Supervision of start-up and of on-going training • Resources to cover salary costs and current operation 4. A broad outline is made of cost-sharing investment and functioning between the different partners in health development. Each unit took into account the logical sequence of all the activities involved in transforming an entire functional health area, maintaining it (e.g., supervision and support for operations), and estimating costs. Costs were split into investment costs and operating costs. Under each section, the source of financing was specified as deriving from cost-sharing with the State, external partners, or the community (e.g., own revenue from the centre, contributions, and local taxes). A schedule for implementation was proposed according to the stage of negotiations and support capacity, to allow timely planning and programming of resource needs. One of the benefits of this approach was that apart from the traditional unit costs (e.g., infrastructure, equipment, and initial seed monies), all of the activities and inputs required to transform an area (creating a ComHC, revitalizing a health centre) were considered together. It would not be possible, for example, to consider isolated training in maternal health or for vaccination, nor community approaches without taking into account the material, technical, and financial support for the other parts of the transformation. Thus it was possible to avoid bottlenecks through lack of coordination and waste resulting from inappropriate implementation. Of course, resources had to be available at the operational level according to the provisional planning, with effective decentralization of their management. The central level (all programmes intermingled) would mobilize resources so that the operational level (with the support of the region) could undertake the transformations. Studies in HSO&P,20,2003
That may appear simple and obvious, in conformity with the new roles of each level. In reality, it was totally different from the way the central level usually operated. Indeed, besides the partitioning that characterized its administration, the central level naturally was more concerned with its own priorities and position than coordinating with other programmes and levels. The development of the Mali-UNICEF health cooperation programme from 1993 to 1997 was the first opportunity for national managers to familiarize themselves with the new method. 30 Points for discussion about the new programming approach were the following: How can vertical programmes that contribute to the MPS evolve, especially since changes in the practical organization of their activity is not foreseen and the new health policy would take a long time to cover the whole country? Should it refuse financing that is not within the scope of the arrangement and priorities of the plan? Is it at liberty not to take national programme priorities into account or to carry out the activities associated with them (training and seminars, supervision)? The questions affirmed the need for negotiations to strengthen the coherence of central level interventions. It was obvious that for social and political reasons, no one would try and stop the flow of support flowing to the regions under the programmes, particularly since effective implementation was only in its infancy. 31 Thus it was almost inevitable that old and new would coexist somewhat uncomfortably. The new policy advocated decentralization, integration, and making the community more responsible. That would take time, and required promoting clear and positive transitions—certainly not an easy thing. Central level managers were often very favourable to change: these included planners, central services officers, and regional directors. Others were indifferent or hesitant: vertical programme officers and some chief doctors. But the structuring and programming of stages became widespread without explicit objections. Validation of the change had to await experience with the initial district plans and installation of the first 30 Gouvernement de la République du Mali et UNICEF (1994) Programme Santé Mali - UNICEF. 92p. Bamako: Gouvernement de la République du Mali - UNICEF. 31 El Abassi A (1998) Le processus d’intégration de programmes au sein d’un Paquet Minimum d’Activités pour les Centres de Santé: l’expérience du Mali. In: Van Lerberghe W & de Bethune X (eds) Intégration et Recherche. Studies in Health Services Organisation & Policy 8, 109-121. Studies in HSO&P,20,2003 37
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 and 36: Health (to such an extent that some
Page 37 and 38: THE ISSUE OF ESSENTIAL DRUGS From i
Page 39: The new strategies were developed w
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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