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

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Table 12. Characteristics of health systems in rural and urban settings Rural setting Urban setting Population Traditional organization. Generally stable. Hybrid organization: modern and Population dispersed. traditional; rapid growth and concentration. Mobility. Life precarious for those living at the fringe. Delinquency, prostitution, and risky behaviour. Community participation Relies on traditional organization. Little Combination of modern and traditional management capacity. Initiatives difficult forms of participation. Presence of managers without support from administration or external and intellectuals. Initiatives possible with partners. little or no support from the administration. Organization and procedures subject to change. Health map Stable regrouping of villages. Negotiation poses Areas by neighbourhoods and map linked to logistical problems for multiple and regular urban development. Negotiation poses contacts. fewer logistical problems than schedule (evening, holidays). Mobilization of resources Qualified human resources rare. Financial and Relative overabundance of human material resources difficult, even impossible, to resources and unemployed managers. mobilize beyond a certain threshold. Mobilization of material resources possible. Service offered MPS by nurse. First level medicalized MPS evolved towards referral activities and favours costeffective curative activities. Referral The DHC is in general the referral and often the Referral opportunities are multiple only possible one. (hospitals, clinics). Management team Authority and technical support essential of The proximity of central level decision developing the district health system. centres favours shortcuts. Hospitals are exempt from coordination by the regional office. Pluralistic system of care Private sector undeveloped. Traditional. Private sector developed, direct access to Virtually a monopoly. Alternative sector hospitals. Alternative sector (traditional, undeveloped. charlatanism, nurses) very developed. Situation of “fierce” competition. 64 Studies in HSO&P,20,2003
Organizing and developing referral in the rural setting THE FIRST LEVEL The DHC—the equivalent of a first referral hospital—had a special status in the district. At the time, it provided first referral level care. The relationship with the periphery was essentially administrative and hierarchical. The DHCs most often had a surgical block, but the premises were unsuitable, the equipment insufficient, and the staff inadequate or unqualified. In its relationship to the community, the reputation of the DHC largely depended on its successes and surgical failures. While it was hoped that an effective referral level would strengthen the quality and the global credibility of the system, it was necessary to rehabilitate, strengthen the technical services, and improve staff skills. These requirements formed part of the district health development plans. Initial programming foresaw the parallel evolution of the first stage and the referral level. The difficulties of mobilizing financial resources to achieve the technical services referral stage (donor and administrative procedures) were such that substantial progress was made only in the developing the first stage. In fact, the workload for the first stage kept the district teams from being in any way able to simultaneously address development of the referral level. An external evaluation team confirmed this observation. 51 It would take many more than the two doctors currently stipulated as the minimum. Three to five doctors would be needed to develop the two levels at the same time. It was therefore decided to start by improving and extending accessibility to the first level. A MULTIPURPOSE TEAM FOR MANAGING THE DISTRICT Considering the level of need in clinical and surgical skills, it was proposed that doctors totally devote themselves to these functions in order to maintain and develop their competence, and to leave the public health roles (supervision of health centres at the periphery) to other staff. Taken to its extreme, this philosophy led to the structural separation of the hospital from its role in public health and the first level. However, the decision was made to keep the principle of a single service and a single team. The arguments were the following: 51 de Champeaux A, Hours B, Maiga M et al. (1994) Evaluation à mi parcours du PSPHR. 5- 23 December 1994. Report. 144p. Bamako: Projet Santé Population et Hydraulique Rurale. Studies in HSO&P,20,2003 65
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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
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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 and 66: transformed into a ComHC? Should th
Page 67: contributed to the debate at the na
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
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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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