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

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managers (chief doctor, representatives of the local administration, NGO
representatives, and ComHC technical managers) participated on the
district health board only as consultants. In the interest of consistency, the
SDHCs were to be organized and managed in the same way as DHCs. The
administration therefore ceased from directly managing first level structures,
but kept the resources and reserved the right to verify that the ComHC was
aiding in effectively resolving the health problems of the community and to
improve health coverage in the country. At the same time, management of
the DHCs and of communes was effectively decentralized with the
participation of the ComHA on the management boards of referral health
centres.
These principles clearly distinguished not-for-profit organizations
from classical private organizations that are not bound by conventional
commitments and develop in a competitive environment. It was probably
illusory to believe that the private sector could contribute significantly to
these objectives in a country without adequate financial means or health
insurance funds to support it. Experiences of other countries confirm the
tendency of the private sector to develop only in zones where the climate is
conducive to cost-effectiveness and profit. 67
With increased direct financing by the communities, the State
responded by giving the private sector the possibility of managing first level
health centres and comanaging the referral level. The relationships and
commitments of each party were specified under an agreement linking the
public services and the ComHAs. This agreement was to undergo regularly
scheduled review. In this context, the non-profit aim was a condition to
ensure geographical and financial accessibility of health services.
A problem remained nevertheless, and that was financial motivation
of staff. In addition to considerations discussed in the following chapter, the
more motivation of personnel depends on financing from central
programmes, the less local control the ComHA will have. In the Malian
context, specific programme contracts offered salary supplements for staff.
Global agreement for the MPS may also affect staff motivation (Table 15).
There is still scope for testing mechanisms to motivate staff and protect
them without reducing the responsibilities of the ComHA or producing
other undesirable effects.
67 Nitayarumphong S & Tangcharoensatmien V (1994) Private health care out of control.
Health Policy and Planning 9, 31-40.
Studies in HSO&P,20,2003