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

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who observed that the chairman of the committee became the favoured
partner of the head doctor for global management of the centre. Only six
months later did the committee invite the nurse to regularly attend the
meetings. 49
While in principle a community with a ComHC benefited from the
same package of care, a problem of equity between health areas remained.
Those with a ComHC had to pay staff salaries, while those with a SDHC
benefited from a nurse paid by the State. For the medium term, the solution
to this problem lay in distributing the support provided by each district. An
alternative would be to redeploy all staff to the benefit of the DHC. In that
case, the R-SDHC would no longer have had an advantage. But it would
complicate the situation of areas where viability was already tenuous.
In any case, everyone was conscious that despite the uniqueness of
the principles and methods it shared with the ComHC, SDHC revitalization
distinguished itself by (i) its historical relationship with the community; (ii)
the fact that the centre was run by a civil servant who had to learn to be
accountable to a ComHA and to accept changes in job description
(especially the regular visits to the villages); (iii) the fact that the financial
contribution of the community was less significant than that for the
ComHC, and that the amount of the appropriation was less certain.
These principles were only really embraced by all from the beginning
of 1994. Thereafter, the number of revitalizations increased rapidly in the
regions.
Specific problems in the urban context
Twenty per cent of the Malian population live in an urban setting. The
capital, Bamako, is Mali’s major health market, constituting 75% of health
expenditures. The big hospitals of the capital report directly to the central
level. The central powers and external partner offices so dominate that it is
difficult for a regional health office to accomplish the tasks that
theoretically are assigned to it.
It is clear that the specifics of the urban setting as shown in Table 12
influenced the process of implementation in Bamako and strongly
49 Direction Nationale de la Santé Publique (1993-1996) Série de rapports de missions
centrales conjointes (DNSP - PSPHR - UNICEF - Partenaires) de supervision des
CSCom/CSA dans les régions. Bamako: Direction Nationale de la Santé Publique -
Ministère de la Santé, de la Solidarité et des Personnes Agées.
Studies in HSO&P,20,2003