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

These simulations deliberately favoured global determination of
operating costs over the alternative option of determining them activity by
activity. This choice was intended to limit the negative consequences of a
rigid cost structure on integrating the different components of the MPS.
The idea was to prevent the ComHC from being tempted to favour
profitable activities to the detriment of others.
Microplanning itinerant activites in the villages was essential to
applying the simulation to the provisional budget of a particular health
centre and estimating the cost of the forward strategy. The structure of the
area, the number of villages and their distribution, as well as the frequency
of visits affect that cost (e.g., fuel and motorcycle maintenance). By
integrating this concrete information into the model, the provisional budget
could assign responsibility to different parties for providing MPS activities
and for balancing the actual budget. Together with the microplan, it
constituted an essential tool for establishing the partnership agreement
linking the ComHA and the State and for evaluating the performance of
the centre through regular reviews.
Careful scrutiny of the provisional operating budget was a crucial
step, allowing the parties concerned (ComHA, decentralized communities,
the State) to determine their respective responsibilities and reciprocal
commitments. Very soon, however, the first simulations gave way to actual
costs. These served to remove doubts about the viability of the ComHCs.
From provisional to balanced budget
Investment costs were estimated to be US$ 17,000, without construction,
and US$ 40,000 when construction costs were included (Table 20). For a
ComHC serving a community of 10,000 inhabitants, that translated to US$
1.7 and US$ 4 per inhabitant, respectively.
The direct contribution of the population and of decentralized
communities to investment was estimated at about US$ 0.7 per inhabitant.
This contribution could be in cash or in kind (e.g., labour or construction
material). Costs were far lower when no construction was required (e.g.,
renting, or old premises in good condition).
The annual operating costs of a ComHC varied greatly between the
urban and rural settings. Table 21 lists costs for a rural health centre. In the
rural setting, the ComHC is generally run by a nurse and rarely includes
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