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

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66 It is in the DHCs that one finds medically qualified personnel in Mali; this situation will continue for a long time. For the foreseeable future, the first level will be provided by nurses. Under these conditions, the level where situational analysis can be carried out, with all its implications, remains the district level. Under this scheme, it would be detrimental to have the chief doctor take on an administrative role as head of the public health office rather than that of a multipurpose medical manager of a team. Separating functions could not help but be reflected in the quality of supervision at the first level and in the relationships between health team members and their relationship with the community. This division of functions and roles does exist in Mali at the regional level (the regional hospital is a separate institution from the regional health office), but at this level, referral is specialized, and the regional health office provides administrative and technical support, not operational support. DISTINGUISHING BETWEEN FIRST LEVEL AND REFERRAL While the ComHC and R-SDHC obviously needed to be strengthened, the fact that the DHC was at times providing first and second level care posed a problem. In addition to chipping away at the prestige of the first level, which one was hoping to reinforce, it affected the quality and efficiency of referral care. 52 Participants agreed on the principle of distinguishing these two functions of the DHC, but support became more muted and even lukewarm as soon as the problem of financial viability arose. The DHCs assured the stability of their everyday operations largely thanks to their first level activities, which sometimes provided more than half the income. Simulations carried out as part of feasibility studies set expected income needed to balance accounts at such a level that it would seem very unwise for a district team to cut this source of financing, especially if the State contribution was not increased. Two formulas were then tested: total separation with community management of the first level in Djenne District, and separate operations and book-keeping, but a single account at Bla. 53 The results are still not in 52 Van Lerberghe W & Lafort, Y (1990) The role of the hospital in the district: delivering or supporting primary health care? Current Concerns. SHS Paper No. 2. Geneva: World Health Organization. 53 Blaise P, Kegels G & Van Lerberghe W (1997) Coûts et financement du système de santé de cercle au Mali. Studies in Health Service Organisation & Policy 5, 1-130. Studies in HSO&P,20,2003
on these experiments, but in both situations, the separation is believed to benefit the organization and quality of services. In Djenne, a considerable increase in use of the first level by the community has been observed, with a decrease in revenue from the hospital without producing an operational deficit. In both situations, the medical team gained precious time that it was able to invest in more complex activities and in supervision. While the general recommendations (annual reviews of the HPRWP and report of the commission on referral) clearly leaned towards separation of activities, the problem of financing referral health centre activities also need to be addressed. An appropriate and lasting solution necessarily had to take into account real costs, subsidies, and the community’s ability to pay. The latter could significantly improve financing of certain events (such as obstetrical and surgical emergencies) by establishing mutual aid or insurance funds (ComHA funds, in relation with the district health community board). Substantial efforts were made in this direction and were well received by the population. Assessment of the financing of the district health system at the end of 1996 supported not only that trend but also combining mobilization of local capital, State subsidies, and the possibility for internal adjustment. 54 At the time, the delay in attracting funds for technical services was used to learn from trial projects in districts with significant referral capacity (Djenne, Bla, Commune V of Bamako District, Koulikoro, Kolondieba), however modest that capacity with respect to minimizing risks in the event of appreciable investment. STRENGTHENING REFERRAL FOR OBSTETRICAL CARE If only for reasons of credibility, it was not possible to completely ignore the referral function of the DHC. The issue was tackled using “perinatality” as the entry point. Coverage of emergency obstetrical care is very weak in Mali. The number of caesareans performed comes nowhere near covering obstetrical needs. Outside Bamako District caesareans are performed in less than 0.2% of deliveries. 55 In Koulikoro District, for example, rates of caesareans for women living in health areas beyond 40 km from the first level hospital were very low (Fig. 12). Thus even the least intervention needs went 54 Blaise P, Kegels G & Van Lerberghe, ibid. 55 Direction Nationale de la Santé Publique (1991-1996) Annuaires statistiques des services de santé. Bamako: Ministère de la Santé, de la Solidarity et des Personnes Agées. Studies in HSO&P,20,2003 67
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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
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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 and 68: contributed to the debate at the na
Page 69: Organizing and developing referral
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
Page 121 and 122:
Figure 24. Performance achieved in
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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
Page 135 and 136:
Table of contents Acknowledgements
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