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

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drugs as a contribution to operations, subsidizing the local development
committee, annual contribution from the community) in addition to
charging services to individual users of the centre. There are drawbacks to
developing health centres based solely on market laws. Such an approach
would have led to the closure of many existing health centres and the
development of more of them in viable areas (urban setting and some rich
rural zones).
The State did not totally disengage from financing the first level
health network. Its contribution remained significant through national
programmes such as the EPI. Nevertheless, the problem of viability of the
ComHCs remained real in a country where geographical accessibility to
health services is very modest.
New cost-sharing
For several reasons, external partners of Mali and the government shared a
genuine desire to improve and extend health coverage in the context of a
redefined role for the State, decentralized communities, associations, and
the population. The new health policy advocated a new cost-sharing for the
health system. 77 The users and the decentralized communities would assume
a significant part of fixed costs at the first level (often through payment of
salaries), and the State took charge of fixed costs for referral structures. The
population contributed directly to financing fixed operating costs and the
purchase of drugs at both the first and second levels (Table 19).
This new cost-sharing took into account the fact that for a long time,
the State had been in no position to finance the health system or to
automatically recruit school leavers for basic training. The government’s
limited means, even though strengthened, needed to be oriented more
towards investment and depreciation of structures at the first level and
towards the district management teams. The State paid particular attention
Solidarité et des Personnes Agées. Guiteye AM & Coulibaly S (1993) Centres de Santé
Communautaires dans le District de Bamako: de la philosophie aux réalités dans le cadre de
la mise en oeuvre de la politique sectorielle de santé au Mali. Report. 60p. Bamako. Magassa
N, Dembele R, Guindo I et al. (1995) Etude de cas: le centre de santé communautaire de
Dougoulo; 22 mois de fonctionnement. 25p. Ségou: Direction Régionale de l’Action Sociale.
De Champeaux A, Hours B, Maiga M et al. (1994) Evaluation a miparcours du PSPHR. 5-
23 December 1994. Report. 144p. Bamako: Projet Santé Population et Hydraulique Rurale.
77 Blaise P, Kegels G & Van Lerberghe W (1997) Coûts et financement du système de santé
de cercle au Mali. Studies in Health Service Organisation & Policy 5, 1-130.
Studies in HSO&P,20,2003