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

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78 not the same teams as before; they had changed, and were more qualified to pursue their committed path. The tools and methods used to introduce the changes were tested and enriched. They were more readily adopted by managers, especially owing to central services being careful not to insist on a foolish uniformity. The health map was recognized by all as the tool needed to negotiate extension of coverage in the districts; it even aroused the interest of the Ministry of Territorial Administration, which worked on the issue of the decentralization and establishment of rural communes. Beyond the village unit, a non-administrative intervillage space was shown to be feasible and suitable for basic development. It seemed appropriate for building the rural communes envisaged by the policy of decentralization. The models put into place clearly differed from past experiences, more so from the point of view of the quality of coverage than of financial accessibility to care. 68 They confirmed a genuine ability to self-finance fixed costs in rural areas, including local costs of preventive activities and part of the investment. The frequently muscular debate reinforced attitudes of tolerance, openness, and a process of real synthesis. Regulations for creating the ComHCs and operating the social-health services were a successful innovation that benefited especially from field experience and widespread, supportive consultations. The adequacy of basic training, with new roles assigned to the doctors and nurses, posed an acute problem. Even the quality of the basic training, particularly that of nurses, remained a pressing preoccupation. Neither the initial training for launching the ComHCs nor continued training could totally alleviate it. 68 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. Directions Régionales de la Santé et de l’Action Sociale de Bamako, Mopti, Ségou, Kayes, Sikasso, Koulikoro, Mali (1993-1996) Etat d’avancement, études de cas, séries de notes techniques et de rapports de supervision des centres de santé de cercle et CSCom/CSAR. Bamako: Ministère de la Santé, de la Solidarité et des Personnes Agées. Magassa N, Dembele R, Guindo I et al. (1995) Etude de cas: le centre de santé communautaire de Dougouolo; 22 mois de fonctionnement. 25p. Ségou: Direction Régionale de l’Action Sociale. Samake S, Dakono G & Guidetti F (1995) Etude de cas du CSCom de Monzombala. Rapport. Koulikoro: Direction Régionale de la Santé. Studies in HSO&P,20,2003
Motivation of health staff received little attention. The modes of motivation, in particular those of ComHCs and revitalized SDHCs, have still to be developed and tested, though some attempts were made. The new relationships between the technical managers of health centres and the ComHAs were also insufficiently consolidated. Non-technical authority was now the province of the ComHAs, and the nurses relied on their technical skills and dialogue with the community to assert their authority. The nurses had not been constrained this way in the past, having been accountable only to the chief doctor and deriving administrative authority from their functional status. Some have been able to adapt; for others, it has clearly been more difficult. A further problem was the persistent confusion over the support modes of external partners when they systematically favoured the use of NGOs and brought them into conflict with the administration. Often the criticism was justified. The administrative bureaucracy served as an excuse to put in place intervention mechanisms directly controlled by NGOs. It is unlikely that these mechanisms promoted development, especially when they did not contribute to achieving a critical mass of knowledge and skills. The shortcomings of the administration were reproduced to various degrees. Table 16. Achievements and problems after initial implementation Achievements Problems • Working models exist in the regions • Viability of the ComHCs remains • Fruitful interaction and support a concern between health personnel and the • ComHA capacities limited population • Relationship between health • Tools and methods tested personnel and ComHA new and • Health map tool adopted and tested not stabilized • New intervillage non-State space • Not all the external partners • The ComHCs in place make the have joined the process difference • Complex situation of urban • Positive atmosphere for exchange and settings debate • Certain reservations expressed • Regulations the result of experience about the obligation made to and consultation ComHA with the State The complex situation in the urban setting, where a plurality of formal and informal health systems coexisted, created a tension that was Studies in HSO&P,20,2003 79
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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
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technical assistants who were exper
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making all the right decisions at t
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plans started with a discussion of
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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 and 74: % Expected births Figure 12. Obstet
Page 75 and 76: ambulance evacuation by the health
Page 77 and 78: The ComHA-BA—the community health
Page 79 and 80: maintaining the centre’s capacity
Page 81: Table 15. Effects of contractual mo
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
Page 125 and 126: situation opened prospects for inte
Page 127 and 128: Managing change Without the project
Page 129 and 130: Figure 27. The position of national
Page 131 and 132: 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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