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

The ComHA-BA—the community health association of the Bankoni
neighbourhood in Bamako—was the first to be created in Mali. 65 It
managed a ComHC in a neighbourhood in Bamako. As a not-for-profit
association, made up of members living in the neighbourhood, it benefited
from official authorization that gave it the moral authority to manage a non-
State public health centre.
This form of organization and autonomy in managing a health centre
(which is neither sectarian nor private for-profit) was a major innovation.
Nevertheless, no mention was made of it in the interministerial order of
March 1991, which was more geared towards decentralization within the
limits of the one-party system. It was necessary to wait until April 1994 for
adoption of the new interministerial order, which took into account the
political changes that had occurred in Mali, and the new experiments in
innovation.
Based on the experience of ComHA-BA, brain trusts for the
ComHCs established by the Ministry of Health recommended institutionalizing
community management of health centres and organizing the
community in ComHAs.
The rapid development of the ComHA and ComHC in Bamako did
not formalize a partner relationship with public services. The regional
health department was outmatched by a process that had the direct support
of external partners and from the energy of young doctors looking for jobs
(recruitment into the public service was no longer assured for outgoing
medical students, and private medical practice was undeveloped).
Test projects under the HPRWP adopted the same principle of
organization. In addition, however, they forged agreements linking
ComHAs to the public health services. The agreements highlighted the
obligation to guarantee the full range of MPS components and the specific
commitments of each party, with the ComHA given explicit responsibility
for the health of the community of a defined area.
The political changes that occurred in Mali with the advent of
multipartyism and democratic elections indisputably influenced the debate
and favoured creation of non-State spaces for the organization and
provision of health care. The community sector and private sector
65 Iknane A (1995) Place de la santé communautaire dans l’offre de soins de qualité avec la
participation active et volontaire de la population: le cas de ASACOBA. 19p. Bamako:
Association de Santé Communautaire Banconi.
Studies in HSO&P,20,2003 73