Partnerships for health in Mali
29 October 2010
In Mali the devolution of health service management to local governments led to friction at all levels, and the inefficient use of resources. An action research programme has helped the emergence of effective partnerships for local healthcare delivery.
Multiparty democracy was installed in Mali in 1991 following a popular revolt. The loss of public confidence in the government’s capacity to promote equitable development also prompted the decision of the new government to decentralise.
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One of the consequences of decentralisation was that, by law, communes became responsible for public health and the provision of basic services, including the funding, construction and operation (equipment and personnel) of community health centres. Throughout the Ministry of Health, this transfer of responsibilities was seen as risky. The district referral hospitals, in collaboration with the community health associations (ASACOs), had previously been responsible for fundraising at the community level, and they regarded the transfer of resources to local governments as a challenge to their power. They also had little confidence in the communes’ ability to manage the health centres, or to recruit and evaluate the performance of health professionals.
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For these reasons, ministry staff were not inclined to cooperate with local governments. They felt that few mayors understood health policy, and ignored their increasingly frequent requests for advice. Nevertheless, the communes started engaging in healthcare management, such as by investing in new community health centres in response to local demand. But some of these new buildings did not meet technical requirements, or investments in personnel and equipment did not comply with health centre plans. Parallel planning and the lack of coordination resulted in the inefficient use of the meagre resources available, and even in duplication. Lack of information, negative perceptions and distrust blocked communication at all levels.
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Although the communes were formally mandated to invite other parties to cooperate, they lacked confidence and authority to initiate dialogue on public health issues. Many councillors failed to understand their new responsibilities, or the importance of delegating certain tasks to experts and specialised organisations.
To address the lack of coordination, SNV and the Royal Tropical Institute (KIT) launched an action research programme in the Koulikoro region of southern Mali. The programme is facilitating the emergence of partnerships around primary healthcare at the commune level, and is coordinated by regional and district health service staff, with advisory support from SNV and KIT.
Action research is a useful approach in situations where the aim is to encourage learning, change and innovation, and where successful approaches and tools can be developed and applied on a larger scale. To ensure that the action research would be embedded in the process of national policy development, and that the results would feed into debates, the idea was first discussed with the ministry and the Directorate of Decentralisation. As a result, a national steering committee was created, composed of representatives of the ministry, the Federation of Community Health Associations, local government and development partners. As the growing frustration was beginning to give rise to open conflicts, the move was welcomed by health staff and councillors at the district and commune levels.
The programme began by bringing together the three parties – communes, ASACOs and health centres – to exchange information, ideas and experiences, and to establish a basis for joint planning and monitoring. In this process, a division of responsibilities and tasks began to emerge. The research, including the development and testing of tools and approaches, was carried out in pilot communes in three districts. The partners established informal local platforms to implement the action research. These platforms are now being institutionalised around the tasks of joint planning, monitoring and evaluation of healthcare performance. The results were monitored through interviews and surveys, and the performance data presented to the steering committee and donors.
After two years of action research in Koulikoro, the partnerships created have been effective in improving healthcare service delivery and awareness of public health issues in general. In this process, several important factors can be identified.
All actors must have access to information. Although policies and implementation guidelines may exist, they may not be accessible or comprehensible to local actors working in other sectors. To overcome this problem, information packages were prepared for all those involved in service delivery. The packages included booklets explaining health policy and the healthcare system, the decentralisation policy and its implications, and planning and participatory monitoring guidelines. This knowledge, and greater awareness of each other’s roles, helped to establish mutual trust among the partners, enabling them to develop a common vision.
Most Malians depend on primary healthcare centres, each of which serves a catchment area with over 15,000 people spread out over several villages. The centres offer basic healthcare, vaccinations and health education, but most are understaffed and poorly equipped. INTERNALLINK Read more...
Activities that will catalyse or trigger collaboration need to be identified. Building functional working relationships is a long-term process, so it is important to start with activities that are relevant to all actors and can be realised within a short time, like vaccination campaigns or health education. Only then should the partners move on to address more complex and sensitive issues, such as the implications of the transfer of responsibility for all aspects of managing the community health centres to the commune level.
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Creating platforms and spaces where debates and negotiation can take place is essential. Workshops at district and commune levels are good starting points from which informal relations often develop. Institutionalisation is important, as after each election some councillors may change, ministry officials may be relocated, and ASACO members can change. The approach was not to create new platforms, but to broaden participation in existing processes. Commune councils now invite health centre staff and ASACO representatives to meetings dealing with health issues, and in return, local government representatives attend ASACO meetings, as well as review meetings organised by the district health team. The local government health committees play a coordinating role.
The capacities of individual partners need to be strengthened to enable them play their respective roles effectively. This involves helping local governments to look at public health within their commune from an inter-sectoral perspective. ASACO staff are now being trained in administrative and financial management and district health service staff in coaching skills and facilitating partnerships.
Joint performance tracking is important. To support participatory monitoring of health indicators, an Essential Information System for Communes (SIEC) has been developed, based on the information system used by the ministry. It is helping communes and ASACOs to understand relevant performance indicators, and how joint monitoring can enable them to act when needed.
The partnerships need to be formalised through performance contracts or agreements that define mutual expectations, roles and anticipated results. In this case, the contract is based on the joint preparation of health centre plans.
Strengthening downward accountability will enhance the voice and influence of the population, particularly the poor, by encouraging all actors to be more responsive to local demands. Local councillors are motivated to invest in public health because they see this as a demand of their electorates, but direct dialogue is still in its infancy.
Decision makers and high-level officials must be involved from the start, since the sustainability and institutionalisation of the partnerships depend on their support and leadership. The creation of a decentralisation unit within the ministry provided an important boost for the process.
From the outset, efforts should be made to build a support network of local capacity builders, including district health officers, local consultancy agencies and NGOs, with the competencies to advise the emerging partnerships.
In Koulikoro the action research has helped actors to find common ground on which to build partnerships. Ministry officials have become increasingly supportive over time, as they accept the idea that managing decentralised healthcare is about sharing responsibilities, knowledge and resources, and not about ceding power. The programme has brought about significant changes in the perceptions and attitudes of all actors with regards to each other’s roles and responsibilities for service delivery at both local and national levels.
Improved access to information means that even non-experts can now participate in discussions on health management in a meaningful way.
The communes are better able to identify priorities and, in collaboration with ASACOs, take action when needed.
At the commune level, health indicators have already begun to improve. In one commune, after the mayor decided to take the lead in a campaign to eliminate tetanus, the vaccination coverage has reached 100%.
The communes are more responsive to the demands of users. A group of nine communes, for example, shared the costs of operating a local ambulance service, but were in arrears. When the women of the area learned about this, they pressed their communes to pay, and succeeded in saving the service.
Communes, ASACOs and health centres are now focusing on other public health issues that had not been addressed before. The communes are more aware of the link between health and clean water and sanitation, for which they are now also responsible, and are increasingly integrating these sectors into local development plans.
While the health centres rely on the ministry for regular funding, the communes are increasingly willing to cover unforeseen expenditures required to respond to emergencies.
In 2006 the decentralisation unit within the Ministry of Health took over the role of coordinating the work of the national steering committee of the action research programme. In recognition of the success of the programme, the unit is facilitating its roll-out in other regions and plans to introduce a training programme on healthcare management for communes. Meanwhile, the research will continue, in order to develop further the methodology and tools to improve the delivery of basic healthcare throughout the country.
T. Hilhorst et al. (2005) Building Effective Local Partnerships for Improved Basic Social Services Delivery in Mali. KIT/SNV Mali.
A. Jeppsson (2004) Decentralization and National Health Policy Implementation in Uganda: A Problematic Process. Lund University.
M. Robinson (Ed) (2007) Decentralising Service Delivery? IDS Bulletin 38(1). Institute of Development Studies.
J. Toonen et al. (2006) Développement d’un système d’information essentielle sur le secteur de la santé pour les acteurs communaux au Mali. SNV/KIT.
World Bank (2003) World Development Report 2004: Making Services Work for Poor People. World Bank/Oxford University Press.