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

transformed into a ComHC? Should the State withdraw its personnel as soon as a
SDHC is managed by a ComHA?
Decisions were based on a group of principles. To begin with,
whether ComHC or SDHC, the first level must provide the MPS and refer
directly to the DHC. That helped to avoid an artificial hierarchical
relationship between ComHC and SDHC. Second, it was expected that in
all cases, the community would organize itself to provide global
management of the health centre, and not only the drugs depot, as had
been envisaged at the beginning under the Bamako Initiative. Finally, the
health map served as the basis for organizing the community approach and
the impetus for negotiations; it differentiated between SDHC area and
ComHC area neither in principle nor in method.
For a SDHC to begin to work this way, it needed to be “revitalized”.
ComHCs and revitalized SDHCs (R-SDHCs) thus existed side by side,
working according to the new principles, with non-revitalized SDHCs
functioning poorly, as before. During the long transition period, the SDHC
network continued to provide services for areas still not covered by the
ComHCs. During this whole period the government kept up support, which
it accorded to the SDHC.
In reality, it was the initial revitalization trials, and in particular those
of Touna in 1993, 48 that got the debate moving towards concrete proposals.
Revitalization of the SDHC of Touna followed exactly the same process as
that for establishing a ComHC. The village communities that made up the
health area were organized in a ComHA and contributed to the initial
investment. A civil servant nurse technically managed the centre. The
nurse provided continuous preventive activities for the sub-district villages
outside the area (with financing from the district), and was accountable to
the committee for managing the centre and evaluating activities for the
villages in the health area.
The early stages of cohabitation were not easy. The nurse was not
invited to the regular meetings of ComHA, but took part in discussions
before and after the meetings. The committee wanted to assure itself that it
had real power. This way of going about things was unsettling for the nurse,
48 Directions Régionales de la Santé et de l’Action Sociale de Bamako, Mopti, Ségou, Kayes,
Sikasso, Koulikoro, Mali (1993-1996) Etat d’avancement, études de cas, séries de notes
techniques et de rapports de supervision des centres de santé de cercle et CSCom/CSAR.
Bamako: Ministère de la Santé, de la Solidarité et des Personnes Agées.
Studies in HSO&P,20,2003 61