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

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ComHA highlighted the fact that mastering the ComHC tool is a process
that requires time and perseverance.
Considerable progress was also made with regard to the hypotheses
and focus on a strategy: (i) it was actually possible to set up a complete MPS
at the first go and to ensure acceptable local management; (ii) the quality of
services and the performance of preventive coverage improved rapidly
enough to make a difference at traditional health centres; (iii) rural health
centres considered the itinerant activities of the nurse as critical in
reinforcing the sense of investment in the ComHC by remote villages
despite additional costs; and (iv) poor basic training for nurses was the
limiting factor in quality of services, notably for curative care. The brief
initial training provided for launch of the ComHCs is only a partial response
to this problem.
“Revitalizing” the SDHCs
Prior to emergence of the ComHC, the primary care network was organized
by the SDHCs. There were 286 of these centres, one per administrative subdistrict.
In general they were managed by a qualified government civil
servant nurse. The staff included two or more workers. The auxiliary nurses
and the matrons who were attached to the centre were most often funded
by the Local Development Committee. A single SDHC serviced between
30,000 and 60,000 inhabitants. Theoretically, it had the responsibility of
supervising structures and health activities at the village level; in practice, it
did not have the means and did not do it.
The debate over these government centres centred on a series of
questions posed with concern and sometimes urgency by staff at all levels:
These are the only structures through which the government shows its presence in
the health sector beyond the main district towns. Will the State have to withdraw
further? The Bamako Initiative envisaged revitalization of these centres; does
community responsibility apply only to management of drugs (community depot,
or to global management of the health centre? Will we have two different ways of
organizing the community to manage first level health centres: ComHC-SDHC?
Is it possible to transform a SDHC into a ComHC? What will the relationship
between the civil servant nurse and the ComHA be? Does the SDHC have
responsibilities beyond the health area that will definitively be its own? Who will
assure preventive services for the rest of the sub-districts if the SDHC is
Studies in HSO&P,20,2003