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

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58 Figure 11. ComHC performance after one year of operation (rates of coverage and use) 100 90 80 70 60 50 40 30 20 10 0 In rural settings geographical accessibility strongly influenced use of the health centre. Use of curative care by village communities where a ComHC existed or was located nearby was clearly higher—0.8-1 new case per inhabitant per year—than for communities living far from the centre. Good performance of certain preventive activities (in particular vaccination) was possible due to the itinerant activities of the nurse in the local villages. But this strategy of regular nurse visits to the villages could not compensate for the distance factor in responding to needs for curative care or increasing its use at the health centre. In urban settings, the frequency of curative care at the ComHC also remained very modest, often fewer than 0.2 new cases per inhabitant. Other factors arose (Table 12), namely, the range of informal and formal offers of care services that prevailed in the city. In a commune of Bamako in 1994, four out of five consultations in modern care were sought in the informal sector. 47 47 Ba SA, Ba SR & de Bethune X (1997) Comment se soigne-t-on en ville? In: Brunet-Jailly E (ed) Innover dans les systèmes de santé. Expériences d’Afrique de l’Ouest, 41-51. Paris: Editions Karthala. Studies in HSO&P,20,2003 DTP3 Ant. Care Curative GETEMA KALABANKORO DOUGOULO TOUNA MOZAMBALA MALI94
REACTION Establishing the MPS with community management indisputably improved the performance of health coverage, while reinforcing autonomy for ongoing operation. Subsequent discussions about the initial achievements were marked by contradictions: - increased enthusiasm and motivation of actors to achieve, and greater confidence and determination to go forward - positive appreciation by some external partners, though not free of scepticism, about the replicability of the initial trials - systematic hunting for weak points by other parties. The criticisms focused on the inability of communities to competently manage the centre; the impossibility of self-financing fixed costs, in particular, the monthly visits to the villages; the support given to the early trials in each region, which makes them hard to reproduce; gaps with regard to the organization and procedures used in the vertical programmes (especially tools). These criticisms did not take into account the fact that the process was only beginning and needed to continue if the goal of change was to be reached. That was particularly true for development of ComHA capacities, where it was necessary to capitalize on experience and disseminate the results. Several months to a year following initial launching of the ComHCs, the criticisms were put into perspective and laid aside. Clear and reiterated support from the central level for these initial trials helped to lessen apprehensions. The support was also intended to drive home the fact that procedures in the existing health centres were not absolute constraints. That allowed maintenance and development of new tools and methods compatible with integrated management of the MPS, despite objections and reservations on the part of national programme managers. For sure, the difference between the initial trial results and the former situation was now evident. ComHA and the regional staff explained and enthusiastically defended their projects. They were in the best position to compare current results with the previous situation rather than with unattained utopias. The continued improvement in quality of care and coverage of preventive care, and in the managerial expertise of nurses and Studies in HSO&P,20,2003 59
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Studies in Health Services Organisa
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Acknowledgements The authors partic
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Limits of past experiences A new he
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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 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: In Dougouolo, a survey 45 revealed
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
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Extension of coverage had to be acc
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priority was always given to the se
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When achievements started to mount
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Faced with increasing pressure, tec
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Figure 24. Performance achieved in
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SDHC; on the right, the area that b
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situation opened prospects for inte
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Managing change Without the project
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Figure 27. The position of national
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commitment score 5 4 3 2 1 0 -1 -2
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Joint central supervision 104 playe
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Table of contents Acknowledgements
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