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

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84 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
to placing the complex and costly referral structures to make them more accessible and to increase the overall efficiency of the health system. Finally, the State was instrumental in ensuring the availability of essential generic drugs with a view to guaranteeing good financial accessibility to care. District management team Referral level partners First level partners Table 19. Principles of cost-sharing Depreciation Salaries Operation Drugs Clientele Government Partners Government Government - Government Government Government User fees Users Government Government Partners Communities and local institutions NGOs Users and local institutions User fees Users Users and local institutions The fact that the State no longer paid ComHC health staff salaries introduced an obvious inequity within the community in ComHC areas. It also made ComHC staff accountable to the community through the ComHA as their employer. These changes in cost-sharing appeared to many as the State pulling back. Inarguably, it presented a difficult burden for the community in many health areas. But given the situation, the only realistic alternatives would have reintroduced the welfare state. Revenue derived from two separate accounts: drugs and charges. This separation was intended to protect the resupply of drugs and to avoid the false impression of liquidity that sometimes arises from a common account. In the past these false impressions led to bankruptcy of a number of costrecovery projects by diluting capital. Generally speaking, the proposal involved deducting a fixed percentage (between 10 and 15%) of the “drug account” to contribute to the overall operations at the centre. The “charge account” collects revenue from fees leveled on transactions (by event) and subsidies, in particular those originating from local and decentralized communities. Studies in HSO&P,20,2003 85
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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
Page 13 and 14:
Community participation in managing
Page 15 and 16:
decentralization, and integration o
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esearchers were often involved in d
Page 19 and 20:
Achievements and problems Declarati
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1990-1992: towards a strategy for c
Page 23 and 24:
technical assistants who were exper
Page 25 and 26:
making all the right decisions at t
Page 27 and 28:
plans started with a discussion of
Page 29 and 30:
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 and 82: Table 15. Effects of contractual mo
Page 83 and 84: Motivation of health staff received
Page 85 and 86: Financing of the sector and viabili
Page 87: financing of the ComHCs was conside
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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