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

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38 ComHCs. 32 It was an example where actual use built confidence in the methods without clearly resolving the underlying problems (evolution and transition in the management of certain vertical programmes), which became increasingly apparent. A TRAINING STRATEGY Between 1989 and 1992 the Family Health Division introduced new training strategies, under a programme that reorganized services for MCH activities. The reorganization proceeded from health centre to health centre with on-the-spot facilitators, in a process that led to the desired change. The limitation of this intervention was that it only concerned MCH, even though the health centres had other needs (e.g., essential drugs, effective curative care, financial and material management, and community participation). Training could not be offered by the specialized service of the central level but required staff or a team in the field with more flexible responsibility and abilities. Whatever its shortcomings, the programme proved the basic utility of on-site training. In the interest of continuation, the staff conducting the training were those in charge of supervising the centre. The district team, including the chief doctor, became indispensable for the training activities associated with the ComHC. The region provided support to the district teams to initiate the process and to develop expertise. They also specified suitable standards and procedures, developed training modules, strengthened regional managers’ teaching skills, and evaluated the results of training. The HPRWP Interinstitutional Group for Training, originally traditional in its approach to training trainers, saw its role evolve in the context of these new responsibilities. A problem to resolve was how to tailor the training programme to the first ComHCs. It was also important to adapt or create the appropriate medium (e.g., integrated questionnaire for mother and child follow-up, schedule, outline for microplan development, 32 Directions Régionales de la Santé et de l’Action Sociale de Bamako, Mopti, Ségou, Kayes, Sikasso, Koulikoro, Mali (1993-1996) Etat d’avancement, études de cas, séries de notes techniques et de rapports de supervision des centres de santé de cercle et CSCOM/CSAR. Bamako: Ministère de la Santé, de la Solidarité et des Personnes Agées. Direction Regionale de la Santé de Segou (1993) Evaluation de l’operationnalité du CSCOM de Dougouolo. Rapport d’évaluation. 27p. Ségou: Direction Régionale de la Santé. Studies in HSO&P,20,2003
managerial instrument tools for follow-up and evaluation of activities, and so on). In the interest of common sense, it was decided that the duration of initial training should not exceed one month, to avoid interfering with plans for extending coverage. A preliminary list of training fellows was inspired by Guinean 33 and Tunisian 34 experiences. In addition to organizing effective curative care and major prevention activities, and prescribing essential drugs, training emphasized - healthy infant care as an integrated activity in itself (nutritional follow-up, vaccination, breastfeeding promotion, vitamin A supplementation, child spacing and promotion of family planning) - using operational questionnaires to support training and for developing instructions for principal activities - organizing and managing the human, material, and financial resources of the centre - microplanning activities, in particular, itinerant activities in the villages and developing and interpreting management control data and monthly reports. Taking into account the insufficiency or inadaptability of some of the modules and tools from vertical programmes, the National Health Office gave the green light for the regions to test new formulas in the ComHCs. This freedom was helpful in implementing the initial ComHCs. Regional and district staff felt they had a stake in the tools they produced and the modules they adapted. Ultimately, experiences could be exchanged in a way that allowed the central level to exercise its role as harmonizer. The autonomy carried two risks: first, centrifugal tendencies—the variability among regions was troubling to a centre uncertain of its new role; second, the loss of time and money, leading to the frequent reinvention of the wheel. The question was one of optimizing the price to pay for staff commitment and sense of investment in the programme. Practical training was the principal method used in building ComHC teams. It began with developing the plan and continued up to supervising the first centre. Strengthened regional office technical support capacities, support and enthusiasm at the central level, and increased exchanges between districts and regions made this approach possible. 35 33 Knippenberg R, Alihounou E, Ndiaye JM et al. (1997) Eight years of Bamako Initiative implementation. Children in the Tropics, 229-230. Paris: CIE. 34 Stroobant A (1979) Expériences de soins de santé intégrés au Cap Bon, Tunisie. Annales de la Société belge de Médécine Tropicale 59 (Supplement). 35 Direction Nationale de la Santé Publique (1993-1996) Série de rapports de missions Studies in HSO&P,20,2003 39
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 and 40: The new strategies were developed w
Page 41: That may appear simple and obvious,
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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