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

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86 From simulation to a provisional operating budget All things considered, establishing a ComHC seemed a difficult and risky venture; it could not be done without a feasibility study that took into account the responsibilities, preliminary revenue, and negotiation of subsidy programmes (e.g., by the State and the local development committee). A simple software package was developed for the feasibility studies based on observations from other cases. 78 Using the software, one could simulate the viability of health areas according to the configuration of the health area (total population and population living within 5 km of the centre, number of villages), fixed charges, expected attendance for communities living near the centre and those living more than 5 km from the centre, preventive coverage, and range of fees as well as the margin on sale of drugs. 79 Population living within 5 km of the health centre. Fig. 15 shows hypothetical attendance for communities living within 5 km of the centre as 0.45 new cases per inhabitant per year, and 0.20 new cases per inhabitant per year for communities living more than 5 km from the health centre. Beyond 5 km from the health centre, attendance for curative care is very low and contributes only marginally to revenues. It turned out that hypothesizing 0.20 new cases per inhabitant per year was too optimistic. The actual figure was closer to 0.10. On the other hand, assuming 0.45 cases for communities living within 5 km of the health centre underestimated the situation in a number of rural health centres. The simulation tested different hypotheses according to the size of the total population of the health area and its distribution, expressed as the percentage of the population living within 5 km from the health centre (30, 50, and 70%, respectively). Revenues from operations became positive for communities of 10,000 inhabitants, 50% of whom were living within 5 km of the centre. In reality, and considering the fact that the State needed to cover depreciation, a critical mass of 3,000-4,000 inhabitants living within 5 km was sufficient to assure the viability of the area. 78 Ministère de la Santé, de la Solidarité et des Personnes Agées - UNICEF (1994) Le financement des centres de santé communautaires: utilization d’un modèle de simulation basé sur des expériences en République du Mali: description du modèle. 7p. Bamako: Ministère de la Santé, de la Solidarité et des Personnes Agées - UNICEF. 79 Traore Nafo F, de Bethune X & El Abassi A (1997) Le financement des centres de santé périphériques; enseignment d’un modèle de simulation. In: Brunet-Jailly E (ed) Innover dans les systèmes de santé. Expériences d’Afrique de l’Ouest, 241-256. Paris: Editions Karthala. Studies in HSO&P,20,2003
Profit on drugs. Another aspect tested in the simulations was the influence of profit margins expected on the sale of drugs. In the rural setting, the global result only became positive with a 40% margin on 29% attendance (Fig. 16). That showed the influence of the profit margin on drugs for the viability of the ComHCs and also the possible side effects of high profit margins. Fixed charges and appropriateness of the workload for available staff. Salaries in both the rural and urban setting needed to be adjusted to fit the volume of work (curative, preventive, and promotional activities). Estimation methods were developed to determine the optimal charges compatible with the financial equilibrium of the centre and a financial accessibility of the service for the community. One of the obvious revelations of the simulation exercises was that having to pay doctors’ salaries made it impossible for most of the rural community health centres to balance their accounts. Fig. 17 presents the workload expected at a centre comprising two workers and providing all MPS activities (including itinerant services). It shows the factors affecting the number of contacts according to the proportion of the population of the area living within 5 km of the centre (30%, 50%, and 70%) due to greater use of curative care. Attendance rates are the same as those used for Fig. 15. Figure 15. Balance sheet of a rural ComHC according to the proportion of the population living within 5 km of the centre (simulation) FCFA 2.000.000 1.500.000 1.000.000 500.000 0 -500.000 -1.000.000 30% 50% 70% 5000 7500 10000 12500 15000 T otal population Studies in HSO&P,20,2003 87
Page 2 and 3:
Studies in Health Services Organisa
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Acknowledgements The authors partic
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Limits of past experiences A new he
Page 9 and 10:
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
Page 17 and 18:
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 and 88: financing of the ComHCs was conside
Page 89: to placing the complex and costly r
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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