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

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