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

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80 difficult to handle. The obligation for the ComHAs to sign an agreement with the Ministry of Health was considered by some to be very restrictive. The response of staff from the Ministry was that by the agreement, the ministry committed itself to a leading role in public health, especially since it was no longer directly in charge of first level health structures. The publication of regulations nevertheless unblocked the situation and helped to relaunch the implementation in the regions and districts. The viability of the ComHCs remained a concern in all respects: with regard to the structure of responsibilities (doctor or nurse employed by the ComHA) and with regard to the context (urban, rural, rural with lowdensity population). Helping the ComHAs to assume their new responsibilities remained a challenge, particularly in rural settings. 69 69 Fassin D, Jeannee E, Salem G et al. (1986) Les enjeux sociaux de la participation communautaire. Les comites de santé a Pikine (Sénégal). Sciences Sociales et Santé 4, 205- 221. Studies in HSO&P,20,2003
Financing of the sector and viability of ComHCs Doubts about the viability of ComHCs In 1990, operational health expenditures were financed by the State (20%) and external aid (5%). Household budgets accounted for 75% of the total. 70 The purchase of drugs remained the most significant item, comprising more than 60% of total operating expenditures. The average health expenditures per inhabitant and per year were estimated at FCFA 2,700 (around US$ 10) at the end of the 1980s, but with significant variations according to the region (Table 17). Table 17. Average expenditures per inhabitant according to the region Place of residence Average expenditures per inhabitant per year Bamaka Sikasso Sekou Other regions Note: US$ 1 = FCFA 273.58 FCFA (1990) FCFA 16,760 (US$ 61) FCFA 1,300 (US$ 4.75) FCFA 1,000 (US$ 3.65) FCFA 900 (US$ 3.28) The average expenditures on drugs by region from PPM sales in 1990 confirm the existence of significant regional disparities and the considerable spending of the capital for health expenditures (Table 18). 71 Table 18. Average expenditure on drugs per inhabitant per year Region Average expenditure for drugs per inhabitant per year Kayes Koulikoro Ségou Mopti Tombouctou Gao Bamako Note: US$ 1 = FCFA 273.58 (1990) FCFA 461 (US$ 1.7) FCFA 617 (US$ 2.25) FCFA 467 (US$ 1.7) FCFA 211 (US$ 0.77) FCFA 138 (US$ 0.50) FCFA 376 (US$ 1.37) FCFA 5,272 (US$ 19.2) 70 Coulibaly S & Keita M (1993) Les comptes nationaux de la santé au Mali. 1988-1991. Initiative de Bamako. Technical Report No.18. 71p. New York: UNICEF. 71 Brunet-Jailly J (1990) La Pharmacie Populaire du Mali dans le contexte de l’Initiative de Bamako. 137p. Bamako: Institut National de Recherche en Santé Publique - UNICEF. Studies in HSO&P,20,2003 81
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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
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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 and 82: Table 15. Effects of contractual mo
Page 83: Motivation of health staff received
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
Page 133 and 134: Joint central supervision 104 playe
Page 135 and 136:
Table of contents Acknowledgements
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