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

The answers to these questions emerged through a mutually
enriching process of debate and practice. Generally, good sense prevailed,
and impasses were sidestepped—though sometimes with difficulty.
Profit on drugs. The profit on drugs was essential to the ComHCs and
the private dispensaries. In terms of helping to operate the health centres, it
was socially and economically justifiable. Of course, the contribution
needed to be reasonable and not to exceed a certain percentage to avoid
becoming an obstacle to affordability. The determining factors in the
affordability of drugs are their availability and actual prescription. For health
centres disadvantaged by distance or dispersed populations, applying a
single profit margin and selling price for every product throughout the
country in the interest of equity could be counterproductive if
standardization mechanisms were not taken into account and if they were
not effectively managed. Case-by-case adjustment of the profit margin
within a reasonable bracket was required in each situation to determine a
fair selling price and to avoid the undesirable effects of different prices in
the same market. In the end, this was the approach taken in Mali.
Care of the poor was left to the discretion of the ComHAs. Some
made formal provisions for it (e.g., funds and authorizations by the
committee). Others omitted it, arguing that the family or the extended
family and eventually the village solidarity fund were sufficient to provide
support. It was considered unwise and premature to complicate
management of the centre with this risky proposition and to endanger the
centre’s sustainability. Whatever the philosophy, the rates of unused
prescriptions give some indication of the inability to pay among those
referred to the health centres. Often less than 5%, this percentage exceeds
10% in the region of Mopti (particularly after the devaluation of the FCFA)
and in places where essential drugs are not still not really available.
The problem of the poor was more serious in emergency referral
situations, where patients needed to cover costs amounting to several tens
of thousands of FCFA. Efforts are under way to develop insurance
mechanisms to meet the cost of evacuations and emergency surgical care.
These efforts are positively perceived both by individuals and the ComHAs.
It is likely that the low rate of case referrals, which affects the overall
efficiency of the health system, was due at least in part to the difficulty in
paying the increased cost of referrals. In any case, it became important to
distinguish efficient management of the centre from the mechanisms
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