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

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70 obstacles at the referral level and improved functioning were crucial to developing the health system and strengthening its impact. 60 A significant degree of progress was made. Development of the ComHCs and R-SDHCs led to improved communication between the first level and the DHCs using a radio-communication system. The organization and financing of evacuations and referrals was negotiated with all partners. Table 13. Rates of caesareans performed according to origin, Bla District, 1995 Distance from the Expected Functional Non-functional Total (%) DHC deliveries health area (%) health area (%) 50 km 3243 - 0.3 0.3 Total 9467 0.85 0.35 0.55 SOURCE: F. Guidetti, G. Kanoko, and A. El Abassi Apart from the classical differentiation of coverage according to distance from the hospital, analysis of the source of caesareans performed in Bla (Table 13) shows a marked difference between areas with ComHCs or R-SDHCs and health areas not yet transformed. 61 In Koulikoro District (Table 14), improving the quality of the technical services in terms of both equipment and staff expertise led to a considerable increase in needs met in 1994. Organizing the referral system and transforming four health areas contributed to maintaining growth. Table 14. Caesareans in Koulikoro District 1993-1995 Year 1993 1994 1995 Expected births 7000 7150 7300 Caesariens 6 (0.1%) 56 71 (1%) performed (0.8%) SOURCE: District Socio-Health Services supervision reports of 1993-1996 To make evacuations financially feasible (their cost sometimes exceeded FCFA 20,000), some of the district teams developed cost-sharing schemes. In Bla, FCFA 4,000 constitutes the lump sum required for 60 Gouvernement de la République du Mali et UNICEF (1994) Programme Santé Mali - UNICEF. 92p. Bamako: Gouvernement de la République du Mali - UNICEF. UNICEF-Mali (1992) La situation des femmes et enfants au Mali. 50p. UNICEF. 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. 61 See District Socio-Health Services supervision reports of 1993-1996. Studies in HSO&P,20,2003
ambulance evacuation by the health service. In Djenne, the ComHA prefinanced evacuations with grants for renewable fuel after discussion in the management committee, thus removing any financial obstacle to evacuating patients. 62 A biannual review of progress and problems is conducted with ComHAs and the whole district health team. Figure 13. Emergency obstetrical evacuations according to distance, Kolondieba District, 1994, 1995, and 1996 % Expected births 6% 5% 4% 3% 2% 1% 0% 1994 1995 1996 0 25 30 33 35 45 45 48 55 60 70 75 90 96 Distance km SOURCE: Data collected by Bamba and A. El Abassi The costs of surgical management, even when streamlined (FCFA 25,000-40,000 for one caesarean 63 ), still constituted a significant hurdle, difficult for marginalized groups in the community to overcome. To finance surgical emergencies and particularly obstetrical emergencies, initiatives 62 Alfani S & Maiga O (1996) Cadre conceptuel pour une organisation du système de santé de référence. 65p. Mopti: Région de Mopti, Cercle de Djenne, Centre de Santé de Cercle de Djenne. 63 Toure Bouka (1995) Les coûts des soins obstétricaux d’urgence au Mali. Bamako: Institut National de Recherche en Santé Publique - UNICEF. Studies in HSO&P,20,2003 71
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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
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Achievements and problems Declarati
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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 and 70: Organizing and developing referral
Page 71 and 72: on these experiments, but in both s
Page 73: % Expected births Figure 12. Obstet
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
Page 123 and 124: 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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