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

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were developed to create mutual health organizations. In Kolondieba, 14
ComHAs have committed themselves in this way and established insurance
schemes to manage obstetrical emergencies, considerably reducing the
financial obstacle. 64 The number of emergency obstetrical evacuations
carried out at the hospital has clearly increased. Since the increase is even
higher for areas reasonably far away from the hospital, the referral system is
the likely cause.
Regulations and contracts: crystallizing the debate
The interministerial order establishing the modes for managing socio-health
services was signed on 15 March 1991. It was a precondition to signing the
loan agreement with the World Bank. The regulations concerned the
organization and functioning of management boards and committees at
different levels (e.g., community, sub-district, and district), and for
programming and managing resources. It exempted revenue generated by
the provision of services from all duties and taxes. While clearly a step
forward, the document still supported the traditional hierarchy (village or
neighbourhood chief) and the administration (e.g., sub-district chief, district
commander) in the composition of councils.
The management committee was appointed, not elected by the
management board. The technical managers at each level were not proper
members with a real say, but advisors. At the lower level, the doctor
belonged to the sub-district health board, and the sub-district nurse
belonged to the community level health board.
The regulations were vigorously criticized and contested during the
institution of multipartyism, following the political events of March 1991.
The criticisms essentially had to do with designation of board members,
non-membership of technical managers on the board, and the fact that the
order linked measures agreed to in the context of the project (HPRWP)
instead of presenting them as the general product of a national policy (as
was anticipated in the conceptual framework of the Bamako Initiative).
64 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