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

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42 coordinate support to verify conformity with the strategies of the new policy. The government of Mali possesses a powerful tool in the HPRWP. Cofinanced by a group of multilateral and bilateral partners, it was able to stimulate and energize a convergent process. The Ministry of Health organized regular meetings of donors, sometimes in the presence of the Minister himself. At the beginning, donors were chiefly partners directly involved in the HPRWP (e.g., the World Bank, UNICEF, EDF, USAID, KFW, and the Fonds d’Aide et de Coopération Française). This group rapidly expanded to include all partners of the Ministry to clearly signify that it was a matter of implementing a new policy and not just one “large project” among others. The formal framework was indispensable in making everyone’s position known, and in creating an environment where progress could be made with partners whose commitments were explicit. A need for follow-up dialogue through either more restricted or less formal meetings was also recognized, to give a hearing to partners who preferred to air their reservations privately. No sooner had implementation begun than criticisms from some of the external bilateral partners and NGOs grew louder. “This is a World Bank project; it has been imposed in the country.” “With so much financing, it will turn into a ‘white elephant’ and will all collapse along the way.” These comments implied a lack of information, but especially the anxiety of partners insufficiently familiar with the previous stages. Concerning the content of the new policy, few specific objections were made, though scepticism was sometimes voiced about the viability of ComHCs in certain regions of Mali, and doubt frankly expressed about the pharmaceutical reform’s chances of success. On the other hand, genuine distress was apparent over the gradual change and role of regional and central projects managed by bilateral and non-governmental bodies. Decisions taken to address the situation included (i) increasing information meetings with NGOs, associations, and bilateral partners at the central and regional level; (ii) explicitly giving first priority to each traditional partner of a district or a region to contribute, within the limits of financing, to implementing the new policy—HPRWP monies would then be used as additional and supplementary resources; and (iii) involving all partners, in particular their technicians, in developing implementation tools through working committees and regional and central workshops. These overtures did not entirely resolve the problems; however, they did create a climate conducive to positive developments. On-going projects Studies in HSO&P,20,2003
that were largely committed did not have the flexibility to adapt to new directions. Some of the expatriate technicians were understandably frustrated when it came time to reconsider projects they identified with very strongly. Time, dialogue, and firmness were needed to reach a positive convergence. The regular meetings organized by the HPRWP coordination unit to exchange information involved a number of external partner technicians in Mali (project officials and technical assistants). These technicians had a characteristic role that added a further component to partners’ decisionmaking processes. This role often responded more to personal than to institutional logic. Sometimes it helped matters, but it could also complicate them. The organization of these meetings led to better understanding of the principal technical problems of implementation, a comparison of points of view, respect for differences, and especially minimized risk of bottlenecks. Notably, coordination of external partners initiated after the events of March 1991 occurred without objection. The policy defined in December 1990 was similarly uncontested: the problem was not to reorient it, but to implement it. Achievements of the mobilization phase The declaration of the new health policy was made on 15 December 1990. In 1992 implementation was still only at the mobilization and trial stage. Nevertheless, one could already point to a number of major achievements. The strategy of regional support and training was defined so districts could meet eligibility criteria. This strategy was different from training trainers in series, and highlighted the significance of support in the district itself to the principal stages of development and implementation of the district health development plan. The minimum that each ComHC needed to provide to demonstrate good financial accessibility—costs of curative care not to exceed FCFA 600 (before the FCFA was devalued) 37 —were defined by the MPS. Creation of 37 Direction Nationale de la Santé Publique (1993-1996) Serie de rapports de missions centrales conjointes (DNSP- PSPHR - UNICEF - Partners) de supervision des CSCOM/CSA dans les régions. Bamako: Direction Nationale de la Santé/Publique - Ministère de la Santé, de la Solidarité et des Personnes Agées. 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 Studies in HSO&P,20,2003 43
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 and 42: That may appear simple and obvious,
Page 43 and 44: managerial instrument tools for fol
Page 45: operational forms to facilitate int
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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