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

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4 of five. Maternal mortality was around 1,000 per 100,000 live births. 1 Health care was inaccessible, and varied greatly from region to region. Barely 30% of the population lived less than 15 km from a health centre. Service at those centres was poor owing to inadequate training and qualifications of personnel, uneven regional distribution, and lack of motivation. With drugs and equipment in short supply, little treatment was available apart from that covered by vertical programmes and projects. People relied largely on traditional healers. Republic of Mali Regions and Districts 0 Miles 100 KAYES 200 Studies in HSO&P,20,2003 Figure 1. Regions and districts of Mali K O UL IK O R O SEGOU SIKASSO TOMBOUCTOU MOPTI KIDAL GAO Districts River Border Regions Health sector allocations revealed a growing gap between what was needed to keep services running well and the resources available from the State budget. 2 Yet households were spending significant amounts of money to 1 UNICEF-Mali (1992) La situation des femmes et enfants au Mali. 50p. UNICEF. 2 Koita A, Brunet-Jailly J, Coulibaly S et al. (1989) Recurrent costs in the health sector. Mali. In: Abel-Smith B & Creese A (eds) Recurrent costs in the health sector. Problems and
purchase drugs from the dispensaries of the Pharmacie Populaire du Mali (PPM). That represented US$ 3 per inhabitant per year throughout the country, and US$ 20 per inhabitant per year in Bamako District. 3 Management of services was centralized and hierarchical, transparency was generally lacking, and compartmentalization was the rule. The community was not involved in managing health services. Faced with the limitations and frequent failures of primary health care projects directed by Village Health Workers, many Malian managers had few illusions about their outcome and sustainability. Despite the amount of available resources, the limited results of vertical programmes such as EPI, Control of Diarrhoeal Diseases, and MCH were obvious. They raised doubts about the efficiency and relevance of specific interventions without a solid base to develop and sustain them. New opportunities From the 1980s, decentralized health planning and programming received strong support in certain regions (e.g., Koulikoro and Mopti), contributing to development of real management capability. However, provision of services and their relative weight was still basically determined at the central level, through vertical programmes. The substantial funds allocated to each of these programmes considerably reduced the impact of decentralized planning exercises. At the 37 th World Health Organization (WHO) regional meeting in 1987, African ministers of health made a commitment to implement the Bamako Initiative. This commitment served to motivate external partners as well as countries themselves to involve people in managing their health, and to promote essential generic drugs. Pioneering projects in creating community health centres (ComHCs) were developed by the Health Development Project (HDP) 4 in Kayes policy options in three countries (Costa-Rica, Jamaica, Mali), 45-92. Geneva: World Health Organization. (WHO/SHS/NHP/89.10). 3 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. Diarra K & Robez-Masson D (1992) Le financement des couts recurrents de la santé dans le cercle de Djenne au Mali. Initiative de Bamako. Technical Report No. 14. 34p. New York: UNICEF. 4 A World Bank-supported project, predecessor of the Health, Population, and Rural Water project (HPRWP), which will be addressed further on. Studies in HSO&P,20,2003 5
Page 2 and 3: Studies in Health Services Organisa
Page 5 and 6: Acknowledgements The authors partic
Page 7: Limits of past experiences A new he
Page 11 and 12: workshops and specialized studies b
Page 13 and 14: Community participation in managing
Page 15 and 16: decentralization, and integration o
Page 17 and 18: esearchers were often involved in d
Page 19 and 20: Achievements and problems Declarati
Page 21 and 22: 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 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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