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

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48 months. The actual time allocated to the district health team was only 6-8 weeks. Some development activities were not budgeted because they did not require travel. Often this was less motivating for the local staff, and gave rise to a few significant delays. In the districts where the extended coverage map and the first ComHC were already in place, finalization of the plan was most rapid: the exercise became less abstract for the district team since an essential element of the plan (the ComHC) was able to draw on real experience. These experiences made it possible to reduce the scope of the initial survey and to orient it more towards a search for pertinent information for health interventions. That avoided the tendency to produce endless monographs. The planning stage was not without its critics: “What is the use of all these planning efforts? The initiative should be left to expand and not be crushed by complicated and unfeasible plans.” “The financing for the plans does not benefit the community; it produces documents that have no follow-up.” These comments had merit, not in raising doubts about the relevance of plans, but to ensure that the emphasis was on the practical side of things, and to put the importance of the document vis-à-vis effective implementation into perspective. In addition to clear differences in sympathies, the debate was marked by the position of officials responsible for planning in the Ministry of Health. In any case, the plan was not an end in itself or the prerogative of specialists, but a tool to help initiators of change to achieve their objectives. In the event, the trial strategies turned out to be the right ones. The support strategies really were designed to help regional staff understand the tools and methods developed, to train district health teams in using them, and to strengthen the interaction between partners and the health teams. At each opportunity, the district and regional teams demonstrated good understanding, thus confirming the appropriateness of the methods. The health maps were useful in illustrating the methods’ advantages and disadvantages. For the doctors, this was often their first in-depth look at their districts. They also had the opportunity to interact with the community outside of consultations and health education sessions. Studies in HSO&P,20,2003
Methods workshop 2 weeks Finalizing the plan and submitting it for financing 1 week The first ComHCs Figure 7. Stages of a district health development plan Situational analysis + description + analysis 6 weeks Negotiating the plan and its local adoption 2-4 weeks Developing and negotiating the health map 4-12 weeks Developing the parts of the plan and budgeting 2 weeks At the beginning of 1993 Mali already had numerous experiences with ComHCs in the regions of Bamako, Kayes, and Sikasso. This first generation of ComHCs were largely credited with having demonstrated that there was a place outside of state structures where initiative could satisfy unmet needs. Still, in addition to the controversy surrounding the communal nature of these initiatives, the reality is that among these ComHCs, there was no example that combined all the elements one might wish to find in it: a community with real responsibility for a defined area, a satisfactory MPS, genuinely autonomous management, and a partner relationship with upper-level public services. The first model ComHCs were based on achievements and lessons learned from past experiences. They depended on the government encouraging their creation in the context of a partner relationship. Accordingly, significant benefits were agreed to by the State together with ComHAs (Table 10). In return, the ComHA was expected to ensure that the ComHC would offer the full range of MPS components for the community of the health area, and that it would manage the ComHC with rigour and efficiency. The initial implementations of the ComHCs, first Studies in HSO&P,20,2003 49
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 and 48: that were largely committed did not
Page 49 and 50: Table 9: Achievements and problems
Page 51: 1993-1995: first achievements Distr
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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