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

maintaining the centre’s capacity to restock drugs. These cases are not
legion, but they illustrate very well the difference in attitude from urban
settings.
Drawing up regulations, and fixing the terms for creating ComHCs
and the modes for managing social-health services, heightened the debate.
Regulations were consequently delayed, which affected implementation of
the new policy. Some of the staff pulled back on their initiatives to avoid
finding themselves at fault with the provisions of the new policy and losing
face with the community or local partners.
The new regulations not only concerned development but also made
constitution of a ComHA a major condition for setting up a ComHC. The
latter was defined as a first level health establishment, created on the basis
of the commitment of a defined population and organized within a ComHA.
Thus the association necessarily emanates from a defined population to
which it is accountable (which differentiates it from a classical association).
This specification entails more of a vision of effective decentralization than
a process that sees the population only as targets or customers. In the
context of other developing countries like Mali, the problems are equally
complex. 66
According to the interministerial order of 21 April 1994, the ComHC
must comprise a dispensary, a maternity, and a depot of essential drugs. The
nurse needed to have a minimum first-stage qualification. The functions of
the ComHC included the obligation to distribute the entire MPS. To create
a ComHC, the ComHA had to conform to the district health map, to
include at least 10% of the population among its members, and to sign an
agreement with the Ministry of Health. That clarified the choices and made
the relationship with the government more one of partners.
Even better, the regulations required each ComHA to be represented
on the district health board, consisting of all the district ComHAs and/or of
the commune, and presided not by an administrative manager, but by the
chairman (elected) of the district development board or the mayor (elected)
of the commune. Each ComHA was thus entitled to vote on a board that
managed the entire district health system. Technical and administrative
66 Broomberg J (1994) Managing the health care market in developing countries, prospects
and problems. Health Policy and Planning 9, 237-251. Frenk J (1993) The public/private mix
and human resources for health. Health Policy and Planning 8, 315-326. Mogedal S & Sissel
HS (1995) Health sector reform and organization issues at the local level: lessons from
selected African countries. Journal of International Development 3, 349-367.
Studies in HSO&P,20,2003 75