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

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44 Health for All was a major asset in the fight for availability of essential generic drugs. It reduced the risk of delays and deadlocks in setting up ComHCs. Techniques for developing the health map were devised and shared with all the managers in each region. Negotiating with the community on the basis of theoretical maps helped to ensure the economic viability of the ComHC at the time and to develop a good dialogue between the auxiliary nursing staff and the community. The debates about the health map and the MPS nevertheless highlighted differences in thinking. These differences converge towards two principal positions: one that increasingly connected ComHA with the private for-profit industry despite it being a not-for-profit association; and a decentralizing mentality that saw ComHA as a form of autonomy recognized by a specific community for having organized and managed the ComHC in its health area under the terms of its partnership relationship with the State. Insofar as it was simply one component of the new health system, development of the private sector posed no problem, and might help to build pluralism in the system. Still, it had a tendency to expand at the heart of the public and community health structures, rather than to develop its own system. Unitary programming by area to improve quality of care and to extend health coverage became a precious tool in a context where vertically managed programmes were on the rise. Nevertheless, the insufficient involvement of vertical programme officers in the process made it difficult to coordinate interventions at central level. Frequent formal and informal exchanges generated a positive spirit of collaboration among all participants and with external partner technicians. This spirit did not exclude differences, but it helped to manage them better. supervision des centres de santé de cercle et CSCOM/CSAR. Bamako: Ministère de la Santé, de la Solidarité et des Personnes Agées. Gouvernement de la République du Mali et UNICEF (1994) Programme Santé Mali - UNICEF. 92p. Bamako: Gouvernement de la République du Mali - UNICEF. Kegels G (1994) Paying for health instead of buying drugs: an experience from western Mali. Annales de la Société belge de Médecine Tropicale 74, 149- 160. Studies in HSO&P,20,2003
Table 9: Achievements and problems of the strategy for change Achievements Problems • Support strategy in the districts • Confusion between ComHAdefined ComHC and the private for- • MPS defined profit sector • Creation of the economic interest • Similarities and differences group Health for All between civil and • Method for developing the health government initiatives map and using it as a negotiating • Insufficient involvement of tool managers of vertical • Unitary programming by area programmes • Collaborative spirit Studies in HSO&P,20,2003 45
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 and 46: operational forms to facilitate int
Page 47: that were largely committed did not
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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