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

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62 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
contributed to the debate at the national level. One could also add to this table the fact that in Bamako, the communes have elected mayors, whereas in rural settings there is no equivalent. The planned rural communes have not yet been created. The initial formation of ComHCs in Bamako began in 1989, 50 well before the Ministry of Health defined the framework for the community sector (April 1994). Often at the initiative of doctors that the public sector was unable to absorb, ComHCs developed unbeknownst to regional staff, who often were not even invited to the inaugurations. Urban ComHC doctors had the tendency to develop unduly technical services. It is worth noting that offers of support and donations from NGOs were numerous. The risk of over-technological development was that it reduced the financial accessibility of services for the community. On the other hand, the automatic and inflexible transfer to the urban setting of the two-level health model, as developed in the rural setting, was also risky and difficult to implement. The social-health development plans of Bamako communes did not envisage developing a referral service in each commune: they already had three hospitals to provide first level services for the six communes in the capital. The role of a health team devoid of referral technical services was very different from that of rural DHC teams. 50 Ag Iknane A, Sangho H & Diwara A (1997) Inventer une médecine de quartier: L’expérience de Bamako. In: Brunet-Jailly E (ed) Innover dans les systèmes de santé. Expériences d’Afrique de l’Ouest, 137-152. Paris: Editions Karthala. Studies in HSO&P,20,2003 63
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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
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workshops and specialized studies b
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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 and 62: In Dougouolo, a survey 45 revealed
Page 63 and 64: REACTION Establishing the MPS with
Page 65: transformed into a ComHC? Should th
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
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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
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Table of contents Acknowledgements
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