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

More documents

Recommendations

Info

52 These principles were not actually put into effect until after the adoption of an interministerial order 40 and the restoration of State authority following the political changes of March 1991. The process had a variable duration, rarely less than 9 months. When building was needed, the duration could be much longer. Collecting contributions from the community then became more difficult, and managing the construction caused delays due to the persistent centralization of this component (Fig. 8). At times it was necessary to press forward even when one or two villages were still undecided in their support; in other cases, the map was modified to take changes into account: villages signing on, for example, or defections of villages that wanted to belong to another area. 41 Often reservations concerned the physical site of the ComHC, and originated either with a rival village of the proposed site or with a relatively large village distant from the ComHC site. Since there is no miracle solution to satisfy everyone, well-defined criteria were systematically discussed. This process helped to lessen the frustration of undecided villages and sowed the seeds for their future participation. Indeed, the process was validated insofar as some villages ended by joining. But there were also cases of villages that decided to withdraw after having initially signed on. For example, in the health area of Dougouolo one major village revoked its participation in the hope of implementing its own ComHC with support from an NGO. In such cases, NGOs considered efforts to develop equitable access to health care services to be an administrative constraint, and their behaviour was not always above reproach. Too much flexibility in modifying the maps once commitments were made could weaken the planning process and threaten the survival of functioning ComHCs. Initial efforts demonstrated that it was possible to introduce a fruitful dialogue between the health teams and the population and to initiate an 40 Ministère de la Santé, de la Solidarité et des Personnes Agées - Ministère des Finances et du Commerce (1995) Arrêté interministériel no. 95-0609/MSSPA-MFC fixant la liste des médicaments essentiels en dénomination commune internationale (DCI). 15p. Bamako: Ministère de la Santé, de la Solidarité et des Personnes Agées - Ministère des Finances et du Commerce. 41 Samake S, Dakono G & Guidetti F (1997) La carte sanitaire: outil de négociation pour le développement sanitaire? In: Brunet-Jailly E (ed) Innover dans les systèmes de santé. Expériences d’Afrique de l’Ouest, 73-84. Paris: Editions Karthala. Studies in HSO&P,20,2003
approach through negotiations, without losing or being caught up in endless details. The starting point was clear. Based on a partner relationship, the community would be offered an opportunity to participate in managing its health problems and to use the health map as a negotiating tool for regrouping villages and creating a viable ComHC. In this way, an intervillage process—not imposed by the administration—began with the promise of new active solidarity in a context broader than a single village. LAUNCHING A COMHC Although benefiting from critical analysis of past experiences and from new tools and methods (clearly defined MPS, standard equipment list, specified initial training field), detailed instructions for launching the ComHC remained to be devised. The fear of erring or of not meeting a multitude of expectations sometimes inhibited initiative. Figure 8 illustrates the successive stages for establishing a ComHC: duration varies between 29 and 59 weeks. Figure 8. Stages and their average duration for implementing a ComHC Environmental study Community approach (village by village and general layout of the area) Choosing where to locate the ComHC 12-24 weeks Launching the ComHC 1 week Supervising the start 26 weeks Creating the ComHA Developing rules and regulations Legal recognition 4-8 weeks Recruiting staff Training staff Forming a committee 6 weeks Developing the ComHC project Approval Agreement 2-4 weeks Putting components in place (building, equipment, initial supply of drugs) 4-16 weeks Studies in HSO&P,20,2003 53
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 and 52: 1993-1995: first achievements Distr
Page 53 and 54: Methods workshop 2 weeks Finalizing
Page 55: evaluation of the approaches was po
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
show all

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

Create successful ePaper yourself

Delete template?

Save as template?